New guidelines: a revolution in cardiac care for pregnant women

• The European Society of Cardiology has published new guidelines on the cardiac care of pregnant women with cardiovascular disease.
• The number of pregnancies in women with heart disease is clearly increasing, mainly due to the older age of mothers at the time of their first pregnancy, the increasing number of adults with congenital heart defects and the increase in comorbidities.
• Interdisciplinary care for pregnant patients with cardiovascular diseases is crucial, and that is why the guidelines elevate the "Pregnancy Heart Team" to the standard in reference centers, says Prof. Agnieszka Tycińska, member of the Board of the Polish Cardiac Society (PTK) and chairwoman of the PTK Guidelines Committee.

Emilia Grzela, Rynek Zdrowia: The latest ESC guidelines on the care of pregnant women with cardiovascular disease are from 2018. Why did we need to update them?

Prof. Agnieszka Tycińska: Firstly, the clinical landscape has changed. In recent years, we have collected a lot of new data from registries – the Registry of Pregnancy and Heart Disease (ROPAC) and the Registry of Peripartum Cardiomyopathies (PPCM). Practice on the wards has shown that three things are crucial: a team of specialists working together from pregnancy planning to postpartum (the so-called Pregnancy Heart Team), an honest discussion and risk assessment before conception, and the safe and thoughtful use of medications during pregnancy, breastfeeding, and postpartum.

Secondly, it's a public health issue. Cardiovascular disease remains a leading cause of maternal morbidity and mortality. The new guidelines are intended not only to assist doctors in making difficult decisions but also to genuinely reduce the risk to women and children, so that despite the burden of cardiovascular disease, women are not afraid to become pregnant.

Third, in this field, traditional, large-scale clinical trials are rarely feasible for ethical reasons. Therefore, updates based on registries and expert consensus are crucial. We need as much systematic data as possible in this group of patients.

What are the most important changes in the new ESC guidelines?

The latest guidelines primarily introduce a shift in the philosophy of care: from simple prohibitions to precise, practical recommendations based on teamwork. The Pregnancy Heart Team is becoming standard practice, and antibiotic prophylaxis is permitted during labor for women at high risk of infective endocarditis. In cardiomyopathies, it is recommended to consider continuation of beta-blockers in most patients, but with vigilant monitoring of fetal growth. In aortic disease, categorical prohibitions are being abandoned in favor of thorough, multidisciplinary counseling for women with vascular Ehlers-Danlos syndrome, and in patients with Marfan syndrome and other hereditary aortopathies, the recommendation to use beta-blockers throughout pregnancy and the postpartum period has been significantly strengthened.

In adults with congenital heart disease—especially where the right ventricle serves as the systemic ventricle—the guidelines move away from automatic advice against pregnancy and require robust, team-based counseling with honest discussion of the truly high risks and shared decision-making.

In acquired conditions, it was emphasized that acute coronary syndrome should be treated as in the non-pregnant state, including modern diagnostics and procedures. In selected women, ablation of recurrent supraventricular tachycardia may be considered, and in exceptional cases, in severe aortic stenosis, minimally invasive bypass techniques may be considered. An important change also concerns valves: a bioprosthesis is recommended instead of a mechanical valve for young women planning motherhood, and in some patients with a mechanical prosthesis and a high risk of thrombosis, continuation of vitamin K antagonists is permitted until approximately 36 weeks of pregnancy.

These adjustments align with the broader message of the guidelines: pregnancies in women with heart disease are increasing, and cardiovascular disease accounts for a significant portion of pregnancy-related deaths. Therefore, early, personalized risk assessment, care in experienced centers, and a clear, collaborative management plan from pregnancy preparation, through labor, and postpartum are crucial.

In highly developed countries, the number of pregnancies in women with heart disease is clearly increasing.

Is the number of women with cardiovascular diseases steadily increasing?

In highly developed countries, the number of pregnancies in women with heart disease is clearly increasing, mainly due to the older age of mothers at first pregnancy, the increasing number of adults with congenital heart defects and the increase in comorbidities.

According to global data, up to 4% of pregnancies are complicated by sleep disorders, and up to 10% when gestational hypertension is included. Sleep disorders currently account for approximately 33% of pregnancy-related deaths, with an estimated 68% of these deaths potentially preventable.

Additionally, women with SN disorders have higher rates of adverse neonatal outcomes (~25%), obstetric complications (17%), and maternal morbidity/mortality (11%), and a history of SN pregnancy is associated with a higher risk of subsequent cardiac events, emphasizing the importance of secondary prevention.

To which centers should high-risk patients be referred? What kind of patients are we talking about here?

We refer high-risk patients to reference centers that have a full Pregnancy Heart Team and access to 24/7 diagnostics and interventions, including cardiac surgery, particularly for aortic disease, and a pulmonary hypertension center.

“High risk” includes women with pulmonary hypertension, Fontan circulation or systemic right ventricular dysfunction, significant left ventricular dysfunction (class III/IV symptoms or low ejection fraction), mechanical valve prosthesis requiring complex anticoagulation, significant and unstable left-sided stenoses, severe coarctation of the aorta, genetic aortopathies (e.g., Marfan syndrome, Loeys–Dietz syndrome, vascular Ehlers–Danlos syndrome) with a large aortic diameter or rapid aortic enlargement, and recurrent or difficult-to-control arrhythmias.

Hospitalization is required in cases of acute decompensation or cardiovascular emergencies (heart failure, shock, pulmonary embolism, acute coronary syndrome including spontaneous coronary artery dissection, acute aortic syndrome), severe or symptomatic coarctation, significant progression of aortopathy (especially near the due date), when a change or intensive monitoring of anticoagulation is necessary in women with a mechanical valve, and whenever the team determines that close hospital supervision and a delivery plan in a highly specialized center are necessary for the safety of the mother and child.

Cardiac care after delivery is as important as during pregnancy

What do the new guidelines recommend regarding cardiological supervision of such pregnant women after delivery?

The new guidelines strongly emphasize that postpartum cardiac care is just as important as during pregnancy. The highest risk of complications occurs in the first week after birth, so we establish a follow-up plan before discharge. In high-risk centers, we often stay with the patient in the hospital for about a week, then arrange a follow-up visit within 7–10 days, another visit approximately 6 weeks after delivery, and, if necessary, reassessments in the following months. For women with aortic disease, severe heart failure, a heart transplant, or a mechanical valve, the scope and frequency of visits are greater.

In parallel, pharmacotherapy is assessed for safety during lactation, effective contraception, and a follow-up care plan are established. If adverse obstetric events, such as preeclampsia or preterm labor, occur during pregnancy, these are considered a sign of increased risk later in life and long-term prevention of uterine diseases is proposed.

The patient is also taught to recognize alarm symptoms during the postpartum period: increasing shortness of breath, sudden-onset chest or back pain, palpitations, fainting, sudden swelling of the limbs, or severe headaches. In such situations, immediate contact with the treating center is necessary.

How important is interdisciplinary care for these women? The new guidelines emphasize the need for a Pregnancy Heart Team in referral centers.

Interdisciplinary care is crucial, which is why the guidelines elevate the "Pregnancy Heart Team" to the standard in referral centers. This team guides women from pregnancy planning through the entire pregnancy, labor, and delivery, and the postpartum period. Its core members include a cardiologist, a midwife/obstetrician specializing in high-risk pregnancies, an obstetric anesthesiologist, and a nurse coordinator.

If needed, a neonatologist, pediatric cardiologist, a specialist in heart valve disease, cardiomyopathy, heart failure, congenital heart disease, pulmonary hypertension, an interventional cardiologist, a cardiac surgeon, an electrophysiologist, a clinical geneticist, a radiologist and cardiac imaging specialist, a clinical pharmacist, and—equally important—a psychologist are also involved. This model of care allows for early and reliable risk assessment for both mother and child, safe treatment selection (including medications compatible with pregnancy and breastfeeding), development of a birth plan, and response to emergencies without wasting time switching between specialists. Psychological support and a clear, shared decision regarding the next steps are equally important—especially for women at very high risk. In practice, this approach translates into fewer complications for both mother and newborn and better long-term health outcomes.

What do the new guidelines say about genetic counseling for pregnant women with cardiovascular disease?

The guidelines emphasize that for many hereditary cardiovascular diseases, including aortopathies, channelopathies, cardiomyopathies, congenital heart defects, and selected forms of pulmonary arterial hypertension and thromboembolism, genetic counseling and diagnosis should ideally be performed before pregnancy. Most of these conditions are inherited in an autosomal dominant pattern, which translates to a 50% risk of transmission to offspring. Identification of a pathogenic or likely pathogenic variant allows for a better risk assessment during pregnancy and tailored management.

It is recommended that the tests be performed in a specialized cardiogenetics center or in a network model, with the participation of a team experienced in test selection, variant interpretation, clinical applications and genetic counseling.

If a family has a known monogenic or chromosomal abnormality, preimplantation diagnosis options should be discussed early, which requires in vitro fertilization and prenatal diagnosis. The choice of path should take into account medical, legal, and social considerations, as well as the availability of procedures. The goal is an autonomous, informed decision by the patient. Hence, early referral to an experienced center with an experienced PHT team is crucial.

Systemic deficiencies in the organization of care for pregnant women with cardiovascular diseases

The new guidelines identify a group of patients in whom termination of pregnancy should be considered due to their high risk of SN. Who are these patients?

We're talking about women classified as Class IV according to the mWHO 2.0 classification—patients at extremely high risk of severe cardiovascular complications or maternal and/or fetal death. In such patients, the guidelines recommend that the pregnancy and cardiology team openly discuss the possibility of termination of pregnancy, without unnecessary delay, as the risk of complications increases with gestational age.

Surgical methods are usually preferred; pharmacological methods remain an option until week 9. Professional psychological support is also essential, as is a parallel discussion about effective contraception in the future.

Where do you see systemic gaps in the organization of care for pregnant women with cardiovascular diseases in Poland?

In Poland, we provide high-quality care, but primarily in academic centers; a coherent, nationwide system is still lacking. The biggest gaps include a lack of referral pathways to referral centers, lack of or delayed access to pre-pregnancy counseling, a lack of an interdisciplinary approach, unequal access to testing, a lack of postpartum monitoring, a lack of regulation and funding for cardiac genetics, and a lack of uniform protocols for high-risk situations. Furthermore, there is insufficient training for primary care providers and emergency departments, which are often the first point of contact for these patients.

The National Cardiology Network Act organizes cardiology care for adults into three levels of reference, but does not create a dedicated module just for pregnant women with heart disease. In practice, pregnant women should be referred to level II-III centers, especially when the risk is elevated.

It is worthwhile to introduce a separate standard of care for patients with cardiovascular disease during pregnancy within the National Heart and Care System (KSK), including the obligation to convene a Pregnancy Heart Team (PHT)—also remotely. Current standards for the management of pregnant women with cardiovascular disease, which are part of the Organizational Standard for Perinatal Care, are insufficient. The standard should define simple criteria for referral, pregnancy planning, diagnostics and treatment plans, as well as a standard for discharge with a postpartum follow-up plan.

We also need to include pre-pregnancy counseling in the benefits package and truly develop cardiogenetics. Such steps would quickly translate into fewer complications for mothers and newborns and more predictable, equitable care nationwide.

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