Management of cardiovascular diseases during pregnancy: ESC Guidelines
The current ESC Guidelines for the Management of Cardiovascular Diseases (CVD) during pregnancy are based on the previous version, published in 2012 together with a systematic literature search from 2011 to 2017, by the ESC Task force nominated for this purpose. The new guidelines have been adapted to facilitate their use in clinical practice and to meet readers’ demands by focusing on condensed, clearly presented recommendations. The guideline document is harmonized with the simultaneously published chapter on the management of CVDs in pregnancy of the ESC Textbook of Cardiology.
- Pre-pregnancy risk assessment and counseling is indicated in all women with known or suspected congenital or acquired a cardiovascular and aortic disease or pulmonary hypertension. Echocardiography is recommended in any pregnant patient with unexplained or new cardiovascular signs or symptoms.
- Management of Women in ‘high risk’ should be discussed in specialized centers by a multidisciplinary team: the Pregnancy Heart Team.
- Vaginal delivery is recommended as the first choice in most patients; except for patients presenting in labor on oral anticoagulants, with aggressive aortic pathology, in acute intractable heart failure (HF), or with severe pulmonary hypertension.
- Pregnancy is not recommended in patients with pulmonary arterial hypertension, in patients with a systemic right ventricle and moderate or severely decreased ventricular function, after Fontan operation and any associated complication, in patients with vascular Ehlers–Danlos syndrome, in patients with dilated aorta, in patients with severe mitral stenosis or with severely decreased left ventricular ejection fraction (LVEF).
- Women with mechanical valves are at high risk of complications (valve thrombosis, bleeding, obstetric, and fetal complications) and should be counseled before pregnancy and managed during their pregnancies in specialized centers by a Pregnancy Heart Team.
- It is recommended to treat women with HF during pregnancy according to current guidelines for non-pregnant patients, respecting contraindications for some drugs in pregnancy.
- Immediate electrical cardioversion is recommended for any tachycardia with hemodynamic instability and for pre-excited atrial fibrillation (AF), for sustained both unstable and stable ventricular tachycardia (VT).
- In all women with gestational hypertension or with hypertension and subclinical organ damage or symptoms, initiation of drug treatment is recommended at systolic blood pressure (SBP)> 140 mmHg or diastolic blood pressure (DBP)> 90 mmHg. In other cases, initiation of drug treatment is recommended at SBP 150mmHg or DBP 95mmHg. SBP 170 mmHg or DBP 110mmHg in a pregnant woman is an emergency, and hospitalization is recommended.
- Low molecular weight heparin (LMWH) is recommended for the prevention and treatment of venous thromboembolism (VTE) in pregnant patients and therapeutic doses of LMWH should be based on body weight.
- Before pharmacological treatment in pregnancy is started, it is recommended to check drugs and safety data.
Pregnancy is complicated by maternal disease in 1–4% of cases. Sudden adult death syndrome, peripartum cardiomyopathy, aortic dissection, and myocardial infarction are the most common causes of maternal death in Europe. Therefore knowledge of the risks associated with CVDs during pregnancy and their management in pregnant women, who suffer from serious pre-existing conditions, is of pivotal importance for advising patients before pregnancy. Since the previous version of the guidelines was published in 2012, new guidelines will come handy in dealing with problems of the cardiovascular system in pregnancy.
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