Pregnancy Heart Team & risk stratification

Recommendation

Class

Level

Women with CVD of mWHO 2.0 II-III and above should be evaluated and managed by a Pregnancy Heart Team from pre-pregnancy through postpartum

I

C

For women with mWHO 2.0 class IV conditions, a Pregnancy Heart Team discussion about the high risk of maternal mortality or morbidity and the related high fetal risk is recommended, including shared decision-making on pregnancy termination with psychological support

I

C

Measurement of BNP and NT-proBNP levels should be considered prior to pregnancy in women with HF of any etiology, including previous PPCM, cardiomyopathy, ACHD, and PAH, and be monitored during pregnancy according to the underlying disorder and in case of new-onset or worsening symptoms

IIa

B

Risk assessment in all women with CVD of childbearing age using mWHO 2.0

I

C

Prophylactic systemic antibiotic therapy may be considered in high-risk delivery

IIb

C

Cardiomyopathies & arrhythmia syndromes

Recommendation

Class

Level

Vaginal delivery is recommended in most women with CMPs, unless there are obstetric indications for cesarean section, severe HF (EF <30% and/or NYHA class III/IV), uncontrolled arrhythmias or severe outflow obstruction (≥50mmHg) in women with HCM, or in women with labor on VKAs

I

C

In women with DCM and worsening EF during pregnancy, counseling on recurrence risk during the subsequent pregnancy is recommended in all cases, even after recovery of LV function

I

C

For women with HCM with symptomatic LV dysfunction (EF <50%) and/or severe LVOTO (≥50mmHg) wishing to become pregnant, counseling by the Pregnancy Heart Team regarding the high risk of pregnancy-related AEs is recommended

I

C

Continuation of beta-blockers should be considered during pregnancy in women with CMPs, with close follow-up of fetal growth

IIa

C

Myosin inhibitors are not recommended in women during pregnancy due to a lack of safety data

III

C

Flecainide, in addition to beta-blockers, should be considered as the antiarrhythmic drug of choice in pregnant women with ARVC

IIa

C

Sotalol may be considered as an antiarrhythmic drug in pregnant women with ARVC, with careful evaluation of QTc and while monitoring for fetal bradycardia, fetal growth and neonate hypoglycemia

IIb

C

Monitoring and treatment of hypokalemia and hypomagnesemia is recommended in pregnant women with primary arrhythmia syndromes suffering from hyperemesis

I

C

Beta-blockers, with pre-pregnancy dose and with nadolol or propranolol as drugs of choice, are recommended during pregnancy in women with LQTS

I

B

Beta-blocker therapy can be continued during lactation in women with LQTS to reduce arrhythmic risk

I

B

Pre-pregnancy dose of nadolol or propranolol is recommended in women with LQT2, particularly in the post-partum period which represents a high-risk period for life-threatening arrhythmias

I

B

Beta-blockers, with pre-pregnancy dose and with nadolol or propranolol as drugs of choice, are recommended during pregnancy and lactation in women with CPVT

I

C

Flecainide, in addition to beta-blockers, is recommended in women with CPVT who experience cardiac events (syncope, VT, cardiac arrest) during pregnancy

I

C

Quinidine therapy should be considered in pregnant women with Brugada syndrome who have arrhythmic events during pregnancy

IIa

C

It should be considered to continue quinidine therapy in women with SQTS throughout pregnancy and post-partum

IIa

C

Quinidine therapy should be considered in pregnant women with SQTS and arrhythmic events during pregnancy

IIa

C

Peripartum cardiomyopathy (PPCM) and heart failure

Recommendation

Class

Level

Counseling for women with PPCM on the recurrence risk during subsequent pregnancy and contraception is recommended in all cases, even after recovery of LV function (LVEF >50%)

I

C

Genetic counseling and testing should be considered in women with PPCM

IIa

C

When a reversible course of HF is assumed, treatment in accordance with HF guidelines should be considered for ≥12 months after complete LV recovery (normalization of LV volumes and EF)

IIa

C

Inotropes and/or vasopressors are recommended in pregnant women with cardiogenic shock, with levosimendan, dobutamine, or milrinone as recommended agents

I

C

ACE-Is, ARBs, ARNIs, MRAs, ivabradine, and SGLT2 inhibitors are not recommended in pregnancy due to adverse fetal effects

III

C

Aortopathies & surgery

Recommendation

Class

Level

For women with a history of dissection or aortic surgery, pre-pregnancy counseling about the high risk by an extended Pregnancy Heart Team in women is recommended, considering the presence and type of genetic variant, aortic morphology, growth rate, and etiology of aortic dissection

I

C

Beta-blocker therapy is recommended throughout pregnancy and postpartum in women with Marfan syndrome and HTAD

I

C

Pre-pregnancy surgery is recommended in women with Marfan syndrome, or LDS with P/LP variants in TGFBR1 or TGFBR2, or nsHTAD with P/LP variants in MYH11, ACTA2, PRKG1, or MYLK, with aortic root diameters ≥45mm; in women with BAV and aortic root or ascending aortic diameter ≥50mm

I

C

Vaginal delivery is recommended in women with aorta <40mm

I

C

Cesarean section should be considered in women with aorta ≥45mm

IIa

C

For women with vascular Ehlers-Danlos syndrome wishing to become pregnant, counseling on the high risk of pregnancy-related AEs by a multidisciplinary team is recommended, considering family history, genetic variants, and previous vascular events

I

C

Cesarean section at 37 weeks is recommended in women with vascular Ehlers-Danlos syndrome

I

C

Congenital heart disease & PAH

Recommendation

Class

Level

Vaginal delivery is recommended in most women with ACHD

I

B

For all women with Fontan circulation who wish to become pregnant, counseling by the Pregnancy Heart Team regarding the high-risk pregnancy-related AEs is recommended

I

C

For women with PAH of childbearing potential who wish to become pregnant, counseling by a multidisciplinary team on the very high risk of pregnancy-related AEs is recommended, and shared decision-making about whether to become pregnant is encouraged

I

C

Clear contraceptive advice should be provided to women with PAH of childbearing potential

I

C

Women with PAH requiring pregnancy termination should be performed in PH centers

I

C

Right-heart catheterization should be considered during pregnancy if there is diagnostic uncertainty or to assist with therapeutic decisions

IIa

C

Endothelin receptor antagonists, riociguat and selexipag are not recommended during pregnancy

III

C

For women with systemic RV (Mustard/Senning or ccTGA), in NYHA III/IV, systemic ventricular dysfunction (EF <40%) or severe TR who wish to become pregnant, counseling on high-risk pregnancy-related AEs by Pregnancy Heart Team is recommended

I

C

In women with significant hemodynamic lesions, discussion about guideline-directed interventions is recommended prior to pregnancy

I

C

Acquired heart disease, ACS, AF and anticoagulation

Recommendation

Class

Level

Manage ACS in pregnant women in the same way as non-pregnant women, including diagnostic investigations and interventions

I

C

In pregnant women with chest pain, exclude life-threatening cardiovascular conditions, including PE, ACS (including SCAD), and acute aortic syndrome

I

C

Low-dose ASA is recommended as the antiplatelet of choice during pregnancy and lactation when single antiplatelet is indicated

I

B

If DAPT is required, clopidogrel is recommended as the P2Y12 inhibitor of choice during pregnancy

I

C

The duration of DAPT in pregnant women undergoing coronary stent implantation is recommended to be the same as in non-pregnant women, individualized by ischemic risk and delivery-related bleeding risks

I

C

Vaginal delivery should be considered in most women with ACS, depending on LV function and clinical symptoms

IIa

C

Continuation of statins may be considered in women during pregnancy with established ASCVD

IIb

C

Target systolic BP <140mmHg and diastolic BP <90mmHg is recommended in pregnant women

I

B

IV labetalol, urapidil, nicardipine, or oral short-acting nifedipine/methyldopa are recommended for acute BP lowering in severe hypertension; IV hydralazine is a second-line option

I

C

Therapeutic anticoagulation with LMWH is recommended for pregnant women with persistent or permanent AF at elevated thromboembolic risk

I

C

Beta-1-selective blockers are recommended for rate control in pregnant women with AF, AFL, or FAT

I

C

Flecainide, in addition to beta-blockers, should be considered for long-term AF rhythm control in pregnancy

IIa

C

Anticoagulation plan (decision to continue VKAs or converting to LMWH in 1st trimester) before or at pregnancy recognition is recommended in women with MHV of childbearing age

I

C

Management of pregnant women with MHV by the Pregnancy Heart Team is recommended

I

C

Weekly or at least biweekly INR monitoring in pregnant women on VKAs is recommended

I

C

Continuation of VKAs during the second and third trimesters until 36th weeks should be considered in women with prosthetic heart valves at higher risk of thrombosis

IIa

C

Bioprosthesis is recommended over mechanical valves in young women contemplating pregnancy requiring a valve prosthesis

I

B

Catheter ablation may be considered in women with recurrent, long symptomatic SVT or with contraindications to pharmacological therapies

IIb

C

Balloon aortic valvuloplasty or TAVI may be considered in selected symptomatic pregnant women with severe aortic stenosis not responding to medical therapy

IIb

C

Adverse pregnancy outcomes (APOs)

Recommendation

Class

Level

CV risk assessment is recommended in women with APOs, to recognize and document APOs during CVD risk evaluation, and to provide counseling on lifestyle measures to optimize cardiovascular health

I

B

In women with persistent postpartum hypertension beyond 6 weeks to 3 months post-partum, initiation of antihypertensive therapy per lactation status is recommended following guidelines

I

B

In cases where healthy lifestyle choices alone are inadequate to control postpartum glucose, pharmacotherapy should be initiated following guidelines

I

C

Women with a history of GDM are recommended to undergo an oGTT 6-12 weeks postpartum, with a repeat assessment at 6-12 months, and regular annual follow-up thereafter to screen for diabetes

I

C

Nifedipine and labetalol (metoprolol if labetalol unavailable) are recommended for uncomplicated postpartum hypertension within first 6 weeks after delivery

I

C

In women with a history of APO, CV risk assessment should be considered at 3 months postpartum, with repeat assessment at 6-12 months after lifestyle interventions, with regular long-term follow-up

IIa

C

Breastfeeding may be considered to lower future CV risk in women with APOs

IIb

C