Cardiovascular Disease in Pregnancy — Management Guideline
Source: 2025 ESC Guidelines for the management of cardiovascular disease and pregnancy, European Heart Journal
Guideline: Strong
Guideline: Conditional
Guideline: Not recommended
ClinicoQ pathway suggestion (not from the cited guideline)
Diagnosis
Diagnostic criteria
Pregnancy is a cardiovascular stress test, and women with heart disease need risk assessment before pregnancy, ideally by a Pregnancy Heart Team. The 2025 ESC guideline anchors risk stratification to the modified WHO 2.0 classification, which incorporates CARPREG II prognostic factors and was refined for arrhythmias, cardiomyopathy, and some acquired heart diseases. Adverse pregnancy outcomes (pre-eclampsia, gestational hypertension, gestational diabetes, fetal growth restriction) are recognized as early markers of future cardiovascular disease.
⚠ Alarm features (investigate before diagnosing)
- Heart failure symptoms in late pregnancy or the postpartum period (consider peripartum cardiomyopathy)
- Severe heart failure (LVEF below 30% and/or NYHA class III-IV)
- Mechanical heart valve with interrupted or inadequate anticoagulation
- High-risk aortopathy
- Hypertrophic cardiomyopathy with severe left ventricular outflow tract obstruction
Initial workup
| Test | When to order |
|---|---|
| Modified WHO (mWHO) 2.0 risk classification | Before pregnancy or at first contact, to define maternal risk and decide on referral to a Pregnancy Heart Team (recommended for mWHO 2.0 class II to III or higher). |
| Genetic testing | Recommended for women with aortic disease and for peripartum cardiomyopathy (Class IIa, level C for PPCM); heritable conditions need counselling on transmission risk and reproductive options. |
| sFlt-1/PlGF ratio | From a secondary summary of the guideline: a ratio of 85 or above, or PlGF below 12 pg/mL, indicates a high likelihood of placental dysfunction and imminent pre-eclampsia, warranting hospitalization and close monitoring. |
Decision Points
❓ What is the clinical question?
Treatment
Risk assessment and care pathway
1
Pregnancy Heart Team assessment using the mWHO 2.0 classification
Guideline recommendation — a Pregnancy Heart Team is recommended for women at mWHO 2.0 class II to III or higher; women in class I to II generally do not need referral
- Dose
- —
- Duration
- From preconception through the postpartum period
- Evidence level
- High
- Avoid if
- —
- If no response
- Counsel on heritable risk and reproductive options where relevant
2
Preconception counselling including heritable conditions and drug review
Guideline recommendation — heritable cardiovascular conditions need counselling on transmission risk and reproductive options, including assisted technologies
- Dose
- Review all cardiovascular drugs before pregnancy (see drugs not recommended below)
- Duration
- Before conception
- Evidence level
- Moderate
- Avoid if
- —
Pre-eclampsia prevention
1
Low-dose aspirin for women at moderate or high risk of pre-eclampsia
Guideline recommendation — women with at least one high-risk factor or two moderate-risk factors for pre-eclampsia (guideline Table 15); the class was not seen in the text reviewed
- Dose
- 75-100 mg once daily at bedtime (the guideline body text gives a range of 75-150 mg)
- Duration
- From week 12 until week 36 or 37 of gestation; stop at week 36 or 37 when pre-eclampsia is the indication
- Evidence level
- High
- Avoid if
- Aspirin hypersensitivity; active bleeding
Mechanical heart valves and anticoagulation
1
Avoid a mechanical valve in women of childbearing age when possible; prefer a biological prosthesis in young women who need valve replacement
Guideline recommendation — choose valves with future pregnancy in mind
- Dose
- —
- Duration
- At the time of valve selection
- Evidence level
- Moderate
- Avoid if
- —
2
Structured anticoagulation plan before pregnancy or immediately on recognition of pregnancy
Guideline recommendation (Class I, level C) — no anticoagulation regimen is truly safe, so decision-making must be individualized
- Dose
- Individualized by the Pregnancy Heart Team and the valve type and thrombotic risk
- Duration
- Throughout pregnancy
- Evidence level
- Moderate
- Avoid if
- —
- If no response
- Plan the timing of delivery to ensure safe and effective peripartum anticoagulation
Peripartum cardiomyopathy
1
Consider peripartum cardiomyopathy in any woman with heart failure in late pregnancy or postpartum
Guideline recommendation — prompt treatment is critical
- Dose
- —
- Duration
- Prompt evaluation
- Evidence level
- High
- Avoid if
- —
- If no response
- Treat heart failure with pregnancy-safe drugs and consider bromocriptine
2
Bromocriptine (for moderate or severe heart failure) with prophylactic-dose LMWH
Guideline recommendation — bromocriptine may be considered (Class IIb); adding at least prophylactic LMWH should be considered (Class IIa, level C); women with moderate or severe heart failure are the preferred candidates and an evidence gap remains
- Dose
- Studied regimens: 2.5 mg daily for 1 week, or 5 mg daily for 2 weeks then 2.5 mg daily for 6 weeks; personalized dosing with dose adjustment is possible. Add LMWH at a prophylactic dose at minimum
- Duration
- Per specialist guidance
- Evidence level
- Low
- Avoid if
- Cannot be given where lactation must continue without specialist advice
- If no response
- Offer genetic testing and counselling; a subsequent pregnancy is discouraged if LV function does not recover
Timing and mode of delivery
1
Vaginal delivery is preferred in most women with cardiovascular disease
Strong (Guideline recommendation) — Class I, level B (upgraded in 2025)
- Dose
- —
- Duration
- At term, planned by the Pregnancy Heart Team
- Evidence level
- High
- Avoid if
- Caesarean is advised when: vitamin K antagonist taken within the last 2 weeks; severe heart failure (LVEF below 30% and/or NYHA III-IV); high-risk aortopathy; hypertrophic cardiomyopathy with severe LVOT obstruction; or acute intractable heart failure
- If no response
- Women on therapeutic-dose anticoagulation need a planned delivery with prior discontinuation of LMWH to avoid spontaneous delivery while fully anticoagulated
Other situations (coronary disease, native valves, after pregnancy)
1
Coronary stent implantation
Guideline recommendation
- Dose
- Aspirin and clopidogrel as in non-pregnant women
- Duration
- As for non-pregnant patients
- Evidence level
- Moderate
- Avoid if
- Per standard antiplatelet contraindications
2
Native valve disease needing surgery
Guideline recommendation (Class IIa, level C) — when maternal mortality risk is high and other treatments have failed
- Dose
- —
- Duration
- When indicated
- Evidence level
- Low
- Avoid if
- —
3
Long-term follow-up after adverse pregnancy outcomes
Guideline recommendation — structured long-term surveillance
- Dose
- Cardiovascular risk-factor screening and preventive counselling for all women with a history of pre-eclampsia, gestational hypertension, gestational diabetes, or fetal growth restriction
- Duration
- Long-term
- Evidence level
- Moderate
- Avoid if
- —
✕ Treatments the guideline advises against
ACE inhibitors, ARBs, ARNIs, direct renin inhibitors, mineralocorticoid receptor antagonists, or SGLT2 inhibitors during pregnancy: The 2025 ESC guideline states that these heart failure drug classes are not recommended during pregnancy.
Pregnancy within the first year after cardiac transplantation: The guideline recommends postponing pregnancy for at least 1 year after cardiac transplantation.
⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.