Cardiovascular Diseases in Pregnancy Clinical Practice Guidelines (2018)

European Society of Cardiology

Reviewed and summarized by Medscape editors

October 01, 2018

The recommendations on cardiovascular diseases during pregnancy were released on August 25, 2018, by the European Society of Cardiology.[1,2,3]

General Considerations

All women with known or suspected congenital or acquired cardiovascular and aortic disease or pulmonary hypertension should undergo prepregnancy risk assessment and counseling. Echocardiographic evaluation should be performed for any pregnant patient with unexplained or new cardiovascular signs or symptoms.

Women in modified World Health Organization (mWHO) class 2-3 or higher are considered “high risk” and their management should be performed by a multidisciplinary team (“Pregnancy Heart Team”) in expert centers.

Induce labor at 40 weeks’ gestation for all women with cardiac disease.

Vaginal delivery is first choice for most patients, with the exception of the following:

  • Patients in labor who are on oral anticoagulants

  • Women with aggressive aortic pathology

  • Patients in acute intractable heart failure (HF)

  • Women with severe pulmonary hypertension

Pregnancy is not recommended in patients with the following conditions:

  • Pulmonary arterial hypertension

  • A systemic right ventricle and moderate or severely decreased ventricular function

  • After a Fontan procedure and any associated complication

  • Vascular Ehlers–Danlos syndrome

  • Aortic dilatation

  • Severe mitral stenosis

  • Severe reduction of left ventricular ejection fraction (LVEF)

Hypertensive Disorders

Initiate antihypertensive drug treatment for all women with a blood pressure ≥150/95 mm Hg, or >140/90 mm Hg in the setting of gestational hypertension or subclinical organ damage or symptoms.

Pregnant women should be emergently hospitalized if their blood pressure is ≥170/110 mm Hg.

Valvular Heart Disease

Women with mechanical valves are at high risk of complications (valve thrombosis, bleeding, obstetric, and fetal complications); they should undergo prepregnancy counseling and pregnancy management by a multidisciplinary pregnancy heart team at expert centers.

Heart Failure

Women with HF during pregnancy should be treated based on current guidelines for nonpregnant patients, taking into account contraindications for some drugs in pregnancy.


Perform immediate electrical cardioversion in the presence of any tachycardia with hemodynamic instability and for preexcited atrial fibrillation (AF), as well as for sustained both unstable and stable ventricular tachycardia (VT).

Venous Thromboembolic Disease During Pregnancy

Low-molecular-weight heparin (LMWH) is the first-line agent for venous thromboembolism (VTE) prophylaxis and treatment in pregnant patients. All therapeutic doses of LMWH should be based on body weight.

Drugs During Pregnancy

Before initiating pharmacotherapy in pregnant women, evaluate drugs and safety data as per the full guideline document and at


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