---

2025 ESC Guidelines: Cardiovascular Disease in Pregnancy - Simplified Notes

---

1. KEY UPDATE FROM 2018

• The 2025 guidelines replace the 2018 version
• Major additions: updated mWHO 2.0 risk classification, new section on peripartum cardiomyopathy (PPCM), new section on long-term effects of adverse pregnancy outcomes (APOs), expanded genetic counselling guidance, and practical clinical algorithms

---

2. THE PREGNANCY HEART TEAM (PHT)

• Who needs one: All women with mWHO 2.0 class II-III or above must be managed by a PHT
• Core team: Cardiologist + obstetrician, expanded with other specialists (neonatologist, anaesthetist, geneticist, psychologist) as needed
• Role: Pre-pregnancy counselling, risk stratification, monitoring throughout pregnancy and post-partum
• Key finding: PHT management reduces maternal mortality and hospital readmission rates
• Women with CVD requesting assisted reproduction (IVF) should NOT be denied outright - all cases must be discussed by the PHT first

---

3. RISK STRATIFICATION (mWHO 2.0 Classification)

---

4. CARDIOVASCULAR CHANGES IN NORMAL PREGNANCY

• Blood volume increases 40-50%
• Cardiac output (CO) increases 30-50% by mid-pregnancy
• Heart rate increases 10-20 bpm
• SVR decreases (causes drop in BP)
• These changes peak at ~28-32 weeks; women with CVD may not adapt adequately, leading to heart failure

---

5. DIAGNOSTIC METHODS

• Echocardiography: First-line imaging for any new or unexplained cardiovascular symptoms (Class I)
• ECG: Safe at any gestational age
• BNP/NT-proBNP: Should be checked pre-pregnancy and during pregnancy in women with heart failure
• MRI (CMR): Preferred over radiation-based imaging; avoid >1.5 Tesla; avoid gadolinium unless absolutely necessary
• CT/cardiac catheterization: Use only when other tools insufficient; keep radiation dose <50 mGy (no foetal anomalies reported below this)
• X-ray: Safe when necessary, shield abdomen

---

6. DRUGS IN PREGNANCY AND LACTATION

SAFE to use:

• Heparin (LMWH/UFH): Safe, preferred anticoagulant; does not cross placenta
• Beta-blockers: Safe (metoprolol, labetalol, propranolol, nadolol); preferred for arrhythmias and hypertension; atenolol is contraindicated
• Methyldopa: Safe antihypertensive (first-line)
• Nifedipine: Safe, effective antihypertensive in pregnancy
• Low-dose aspirin (up to 300mg/day): No teratogenicity
• Digoxin: Safe for rate control in AF with HF
• Flecainide/sotalol: Safe for arrhythmias in structurally normal hearts
• VKA (warfarin): Safe in 2nd and 3rd trimester for prosthetic valves (not 1st trimester - teratogenic)

AVOID / CONTRAINDICATED:

• ACE inhibitors, ARBs, ARNIs: Contraindicated in all trimesters - foetal renal failure and death
• MRAs (spironolactone), ivabradine, SGLT2 inhibitors: Contraindicated
• DOACs (rivaroxaban, apixaban, dabigatran): Not recommended during pregnancy
• Amiodarone: Contraindicated in routine use (causes foetal thyroid dysfunction, bradycardia); may be used as single dose in VT storm or cardiac arrest emergency
• Ticagrelor: Contraindicated (embryotoxic)
• Statins: Generally avoid; continuation may be considered in women with established ASCVD (Class IIb)
• NSAIDs: Avoid in 3rd trimester (premature ductus closure)

Lactation:

• LMWH, VKA, heparin: Safe
• Metoprolol, labetalol, propranolol: Safe (preferred beta-blockers)
• Dabigatran and rivaroxaban: May be used cautiously (minimal excretion into milk)
• Gadolinium contrast: Interrupt breastfeeding for 24h

---

7. ANTICOAGULATION IN PROSTHETIC HEART VALVES (MHV)

• A pre-agreed written anticoagulation plan is mandatory before pregnancy (Class I)
• VKA (warfarin): Best protection for the valve; safe in 2nd and 3rd trimester
  • Warfarin dose <5mg/day: Can continue VKA throughout (even 1st trimester) - lower embryopathy risk
  • Warfarin dose >5mg/day: Switch to LMWH in weeks 6-12 to reduce embryopathy risk
• LMWH: Use in 1st trimester (weeks 6-12); monitor anti-Xa levels (0.8-1.2 U/mL); do NOT use fixed doses
• At delivery: Switch to UFH, stop 4-6h before planned delivery; restart anticoagulation 7-14 days post-partum after wound healing

---

8. CONGENITAL HEART DISEASE (ACHD) IN PREGNANCY

• Women with ACHD represent the largest group of pregnant women with CVD
• Foetal echocardiography at 18-22 weeks recommended if parents have CHD (detects ~80% of significant defects)
• Simple repaired lesions (ASD, VSD, PS): Usually low risk (mWHO I-II)
• Complex CHD (Fontan, Eisenmenger, single ventricle): High risk (mWHO III-IV)
• Eisenmenger syndrome: mWHO IV - pregnancy strongly discouraged; mortality up to 50%

---

9. AORTOPATHIES IN PREGNANCY

• Marfan syndrome:
  • Aorta ≥45mm: Pregnancy contraindicated (mWHO IV)
  • Aorta 40-45mm: High risk (mWHO III) - elective repair before pregnancy recommended
  • Aorta <40mm: Can consider pregnancy with close monitoring
  • Serial echo every 4-8 weeks during pregnancy
• Bicuspid aortic valve (BAV):
  • Aorta >50mm or ASI >25mm/m² in Turner: mWHO IV
  • Aorta 45-50mm: mWHO III
• Turner syndrome: Screen for aortic size; co-arctation increases risk
• All aortopathies: Beta-blockers recommended to control heart rate and BP
• Caesarean section recommended if aortic root >40mm

---

10. VALVULAR HEART DISEASE

• Mitral stenosis (MS):
  • Severe MS: mWHO IV - intervene before pregnancy if possible; or balloon valvuloplasty during pregnancy if needed
  • Moderate MS: mWHO III
  • Rate control with beta-blockers
• Aortic stenosis (AS):
  • Severe symptomatic AS: mWHO IV - treat before pregnancy
  • Severe asymptomatic AS: mWHO III
• Valve regurgitation: Better tolerated due to reduced SVR in pregnancy
• Valve surgery during pregnancy: Only if maternal mortality risk is present and all other options fail (Class IIa)

---

11. PERIPARTUM CARDIOMYOPATHY (PPCM)

• Definition: New HF with EF <45% in last month of pregnancy or within 5 months post-partum, with no other identifiable cause
• Treatment:
  • Pre-delivery: Avoid ACE-I/ARB; use hydralazine + nitrates for afterload reduction, beta-blockers (metoprolol), diuretics
  • Post-delivery: Start ACE-I/ARB/ARNI + beta-blocker + MRA + SGLT2i (same as standard HFrEF)
• Bromocriptine: May be considered to suppress lactation and promote LV recovery (Class IIa)
• Recovery: ~50% recover LV function within 6 months; do NOT take contraceptive pill (thrombotic risk, may worsen recovery)
• Subsequent pregnancy: Only consider if EF fully normalized; re-discuss with PHT
• Genetic counselling and testing should be considered; PPCM has a genetic component (e.g., TTN mutations)

---

12. HYPERTENSION IN PREGNANCY

Classification:

• Pre-existing/chronic hypertension: Diagnosed before 20 weeks gestation
• Gestational hypertension: New onset at ≥20 weeks, no proteinuria/organ damage
• Pre-eclampsia: Hypertension + proteinuria OR organ dysfunction (liver, kidney, CNS, haematological) at ≥20 weeks
• Threshold for treatment: BP ≥140/90 mmHg; severe = ≥160/110 mmHg

First-line antihypertensives:

1. Methyldopa (oral)
2. Labetalol (oral/i.v.)
3. Nifedipine (oral)
4. Hydralazine (i.v. for severe acute hypertension)

Pre-eclampsia prevention:

• Low-dose aspirin (100-150 mg/day) from weeks 12-36 in high-risk women (Class I)
• Calcium supplementation in women with low intake

Severe pre-eclampsia / eclampsia:

• Magnesium sulfate (MgSO4) for seizure prevention and treatment (Class I)
• Delivery is the definitive treatment

---

13. ARRHYTHMIAS IN PREGNANCY

SVT (Narrow QRS Tachycardia):

• Haemodynamically stable: Vagal manoeuvres → i.v. adenosine (6-18mg) → i.v. metoprolol → i.v. verapamil
• Haemodynamically unstable: Direct current cardioversion (DC cardioversion) - safe in all trimesters

Atrial Fibrillation (AF):

• Most clinically relevant arrhythmia in pregnancy; increasing incidence
• Rate control: Beta-1 blockers (metoprolol), verapamil, digoxin (if HF present)
• Rhythm control (preferred): Flecainide, sotalol for structurally normal hearts
• Anticoagulation: Use LMWH or VKA (CHA₂DS₂-VASc score applies; any score ≥1 warrants anticoagulation)
• DOACs: NOT recommended during pregnancy

Ventricular Arrhythmias:

• LQTS: Beta-blockers (nadolol or propranolol) throughout pregnancy and post-partum (Class I); avoid QT-prolonging drugs
• CPVT: Beta-blockers + flecainide if cardiac events occur (Class I)
• VT storm emergency: Amiodarone can be used as single dose

Bradyarrhythmias:

• Congenital AV block: Prophylactic temporary pacemaker NOT needed if asymptomatic, HR ≥50 bpm, normal anatomy (Class III)
• Pacemaker implantation can be safely done in pregnancy if indicated

---

14. VENOUS THROMBOEMBOLISM (VTE) / PULMONARY EMBOLISM (PE)

• Pregnancy increases VTE risk 4-5x
• Diagnosis of PE: CTPA (preferred); ventilation-perfusion scan if CTPA unavailable
• Treatment of PE: LMWH (therapeutic dose) - first-line (Class I); UFH in haemodynamically unstable patients
• Anti-Xa monitoring only needed in renal insufficiency or obesity (not routine)
• Duration: At least 6 weeks post-delivery; total minimum 3 months
• Thrombolysis/surgical embolectomy: Only for life-threatening PE when anticoagulation fails

---

15. CARDIAC ARREST IN PREGNANCY

• Causes: PE, haemorrhage, eclampsia, amniotic fluid embolism, sepsis, cardiac disease
• BLS modifications:
  • Left uterine displacement (manual, continuous) in women ≥20 weeks (Class I)
  • IV access above diaphragm (Class I)
  • Do NOT withhold any drug due to teratogenicity concerns (Class I)
  • Chest compressions same as non-pregnant
  • Defibrillation: Anterolateral pad placement, lateral pad under breast
• Perimortem caesarean section: Prepare immediately; consider if initial resuscitation fails (goal: within 5 minutes of arrest)
• If magnesium infusion running (pre-eclampsia): Stop infusion, give calcium gluconate

---

16. CORONARY ARTERY DISEASE (CAD) / ACS

• SCAD (Spontaneous Coronary Artery Dissection): More common in pregnancy/post-partum than in non-pregnant women - always exclude
• Manage ACS in pregnancy the same as non-pregnant (including PCI) (Class I)
• Antiplatelet: Low-dose aspirin preferred; clopidogrel as P2Y12 if DAPT needed (NOT ticagrelor)
• DAPT duration: Same as non-pregnant women; individualize based on ischaemic vs. bleeding risk
• Statins: Usually avoid; may cautiously continue in women with established ASCVD (Class IIb)
• Delivery: Vaginal delivery preferred in most ACS cases (Class IIa)

---

17. HEART FAILURE IN PREGNANCY

• Cardiogenic shock: Levosimendan, dobutamine, milrinone are recommended inotropes (Class I)
• AVOID in pregnancy: ACE-I, ARBs, ARNIs, MRAs, ivabradine, SGLT2 inhibitors (Class III)
• Diuretics: Use with caution (furosemide); avoid aggressive diuresis
• Mechanical support (VA-ECMO, IABP) may be needed in refractory cardiogenic shock

---

18. HEART TRANSPLANT AND PREGNANCY

• Postpone pregnancy until at least 1 year post-transplant (Class I)
• Monitor immunosuppression drug levels every 4 weeks until week 32, every 2 weeks until week 36, then weekly until delivery, and for 6-12 months post-partum (Class I)
• Tacrolimus: Safe; higher doses needed (increased renal clearance)
• Mycophenolate mofetil: Teratogenic - switch to azathioprine before pregnancy

---

19. DELIVERY PLANNING

• Most women with CVD can deliver vaginally with epidural analgesia
• Caesarean section reserved for:
  • Obstetric indications
  • Women on anticoagulation with delivery imminent
  • Aortopathy with aortic root >40mm
  • Severe haemodynamic compromise
  • Marfan/other HTAD with aorta >45mm
• Epidural/spinal anaesthesia: Preferred (reduces haemodynamic stress of labour)
• Second stage: Assisted delivery (forceps/vacuum) to reduce pushing effort in high-risk women
• Intrapartum monitoring: Continuous fetal heart rate monitoring; maternal BP and oxygen saturation

---

20. LONG-TERM EFFECTS OF ADVERSE PREGNANCY OUTCOMES (NEW 2025 SECTION)

• Adverse Pregnancy Outcomes (APOs) include: pre-eclampsia, gestational hypertension, gestational diabetes, preterm birth, SGA infant, pregnancy loss
• Women with APOs have increased long-term risk of CVD (hypertension, coronary disease, stroke, heart failure)
• Recommendation: All women with APOs should have a cardiovascular risk assessment (Class I), lifestyle counselling, and ongoing monitoring
• APOs should be documented as CVD risk factors in future clinical encounters

---

21. CARDIO-ONCOLOGY IN PREGNANCY

• Pregnant women with cancer needing cardiotoxic therapy should be co-managed by the PHT and the cardio-oncology team (Class I)
• Decisions on timing of cancer treatment vs. foetal wellbeing require multidisciplinary discussion

---

QUICK REFERENCE: KEY "DO NOT DO" LIST

---