Novel ESC guidelines for the management of cardiovascular disease and pregnancy

Prof. Julie de Backer (University of Ghent, Belgium) and Prof. Kristina Hermann Haugaa (Oslo University Hospital Rikshospitalet, Norway) shared the most important changes to the ESC guidelines for the management of cardiovascular disease in pregnancy [1].

A first important change is the removal of the class 3 recommendation against pregnancy in women at extremely high maternal mortality risk or severe morbidity. Instead, a new class 1 recommendation now states that ‘expert counselling by Pregnancy Heart Team is required, with clear and thorough discussion of very high pregnancy risk and shared decision-making process regarding termination if pregnancy occurs’. “This recommendation applies to patients with various disease entities, such as vascular Ehlers-Danlos syndrome, aortic dissection, Fontan circulation with complications, and pulmonary arterial hypertension (PAH),” added Prof. de Backer.

The recommendation that ‘vaginal delivery is recommended in most women with cardiovascular disease (CVD)’ was adjusted from level C to level B. Another delivery-related change was the revised flowchart for patients treated with anticoagulants. Prof. de Backer explained that vaginal delivery is usually safe for women on heparins. In contrast, Caesarean section is recommended if vitamin K antagonists were administered within 2 weeks before delivery to improve foetal safety. In addition, to avoid haemorrhagic events, delayed re-initiation of anticoagulants is recommended in certain cases.

Another addition is a class 1/B recommendation to undertake a cardiovascular risk assessment in women with adverse pregnancy outcomes (APOs), to recognise and document APOs during CVD risk is evaluated, and to provide counselling on the importance of healthy lifestyle choices that optimise cardiovascular health.

Furthermore, indications for pre-pregnancy aortic root and/or ascending aortic surgery should be guided by aortic morphology, underlying pathology, family history, genetic variant, previous vascular events, and patient preference (1/C).

The authors also created a concise table for patients with congenital heart disease to outline maternal risk, obstetric and foetal risk, monitoring advice, and pregnancy management and delivery recommendations across various conditions, such as shunt lesions, Ebstein anomaly, transposition of the great arteries, and left ventricular outflow tract obstruction.

For women with PAH, it is recommended to provide clear contraceptive advice if they are of childbearing potential (1/C). Additionally, endothelin receptor antagonists, riociguat, and selexipag are not recommended for these women during pregnancy (3/C).

In pregnant or post-partum women with suspected venous thromboembolism (VTE), an immediate formal diagnostic assessment with validated methods is recommended and should not be postponed (1/B).

Prof. Hermann Haugaa noted that the new guidelines include clinical scenarios, with algorithms for the management of pregnant women with specific cardiovascular conditions. These scenarios cover chest pain and pregnancy, acute heart failure and peripartum cardiomyopathy, cardiac arrest, and ventricular arrhythmias.

“We also added a figure with drug recommendations and contraindications for the various cardiovascular diseases in women who are pregnant or lactating,” said Prof. Hermann Haugaa. Finally, the guidelines include an extensive new chapter on primary arrhythmia syndromes and cardiomyopathies.

1. De Backer J, Hermann Haugaa K, et al. 2025 ESC guidelines for the management of cardiovascular disease and pregnancy. ESC Congress 2025, 29 August – 1 September, Madrid, Spain.

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Posted on 7 November 20257 November 2025