2018 ESC Guidelines for Management of CVD During Pregnancy

Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al.
2018 ESC Guidelines for the Management of Cardiovascular Diseases During Pregnancy. Eur Heart J 2018;Aug 25:[Epub ahead of print].

The following are key points to remember from the 2018 European Society of Cardiology (ESC) Guidelines for the Management of Cardiovascular Diseases during pregnancy:

Risk and Management:

  • Risk assessment in all women with cardiac diseases of childbearing age should be performed using the modified World Health Organization (mWHO) classification of maternal risk. The risk of adverse events, frequency of visits during pregnancy, and location of delivery should be tailored to the class of risk. Additional predictors of maternal and neonatal events should also be assessed and discussed.
  • High-risk patients should be managed at expert centers with a multidisciplinary pregnancy heart team.
  • Vaginal delivery is recommended as first choice in most patients, with a few exceptions.

Valve Disease:

  • Women with mitral stenosis with valve area <1.0 cm2 are recommended to have intervention prior to pregnancy.
  • Women with indications for valve surgery prior to pregnancy should undergo intervention or surgery before pregnancy. The choice of valve prosthesis should involve consultation with a pregnancy heart team.

Anticoagulation of Mechanical Valves:

  • Pregnancy in women with mechanical heart valves involves complex decision making and meticulous anticoagulation. Women with mechanical valves should be managed at a center with a multidisciplinary pregnancy heart team.
  • There are no Class I recommendations for anticoagulation during the first trimester, but warfarin is preferred in the guidelines (instead of low molecular weight heparin [LMWH]) if the dose is <5 mg/day.
  • Pregnant women with mechanical valves maintained on <5 mg/day of warfarin are recommended to continue with warfarin during the second and third trimesters until the 36th week.
  • LMWH needs to be managed carefully by monitoring peak anti-Xa levels, and targeting trough levels of ≥0.6 IU/ml may also be considered. Frequent monitoring is needed.
  • Changes in anticoagulation regimen during pregnancy (i.e., transitioning between LMWH, warfarin, unfractionated heparin) are recommended to occur in the hospital.


  • Food and Drug Administration (FDA) pregnancy categories A-X were formerly used for medications, but decision making should now be based on updated labeling, clinical safety data noted in the guidelines, and reference to www.safefetus.com.

Aortic Disease:

  • Pregnancy is not recommended in women with high-risk aortic disease defined as Marfan syndrome or other heritable thoracic aortic disease with aorta >45 mm, bicuspid aortic valve with aorta >50 mm or >27 mm/m2 body surface area (BSA), or Turner syndrome with aortic size index >25 mm/m2 BSA.
  • Beta-blocker therapy throughout pregnancy should be considered in women with Marfan and other heritable thoracic aortic diseases. In women with (history of) aortic dissection, cesarean delivery should be considered.


  • Patients with peripartum cardiomyopathy and dilated cardiomyopathy should be counseled about the risk of recurrence during subsequent pregnancy, even after recovery.
  • The ESC guidelines state that the use of bromocriptine treatment may be considered to stop lactation and enhance left ventricular recovery (Level IIb); of note, this recommendation has been challenged by some experts. If bromocriptine is used, prophylactic (or therapeutic) anticoagulation should be given (Level IIa).


  • A pregnant woman should be hospitalized if her systolic blood pressure is ≥170 mm Hg, or diastolic blood pressure is ≥110 mm Hg.
  • Initiation of drug treatment is recommended for blood pressure ≥150/90 mm Hg, or >140/90 mm Hg in the presence of gestational hypertension or subclinical organ damage or symptoms. Methyldopa, labetalol, and calcium antagonists are the drugs of choice.

Highest Risk Pregnancy:

  • Pregnancy is not recommended (mWHO IV) in women with the following diagnoses: Pulmonary arterial hypertension, severe ventricular dysfunction (ejection fraction <30% or New York Heart Association class III-IV), peripartum cardiomyopathy with residual impairment, severe mitral stenosis, severe symptomatic aortic stenosis, systemic right ventricle with moderate or severe decreased ventricular function, severe aortic dilatation (as noted above), vascular Ehler-Danlos syndrome, severe (re)coarctation, and Fontan with any complication.

Keywords: Aneurysm, Dissecting, Anticoagulants, Aortic Coarctation, Aortic Valve Stenosis, Blood Pressure, Body Surface Area, Bromocriptine, Cardiomyopathy, Dilated, Cardiology Interventions, Dilatation, Heart Defects, Congenital, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Heparin, Heparin, Low-Molecular-Weight, Hypertension, Pregnancy-Induced, Hypertension, Pulmonary, Labetalol, Lactation, Marfan Syndrome, Methyldopa, Mitral Valve Stenosis, Peripartum Period, Pregnancy, Primary Prevention, Risk Assessment, Turner Syndrome, Ventricular Dysfunction, Ventricular Function, Warfarin, Women

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