The European Society of Cardiology (ESC) released updated guidelines today at ESC Congress 2025, shifting the focus in high-risk pregnancies from restrictive medical advice to shared decision-making and respect for women’s autonomy.
Traditionally, women with rare but serious health conditions such as vascular Ehlers-Danlos syndrome or pulmonary arterial hypertension were strongly advised against pregnancy. The new guidance instead recommends that these women receive counseling from a multidisciplinary team, which should consider genetic background, family history, and past vascular events when assessing risks.
The update was developed by an international panel of experts co-chaired by Professor Julie De Backer of Ghent University and Professor Kristina Hermann Haugaa of Oslo University Hospital.
“More women with a history of cardiovascular disease are now considering pregnancy, thanks to advances in survival after congenital heart disease, organ transplants, and cancer treatment,” said Professor De Backer. “Our updated guidance moves away from a rigid ‘pregnancy is forbidden’ approach, allowing women to make fully informed choices with appropriate support.”
Cardiovascular disease is the leading cause of non-obstetric maternal death, accounting for one-third of pregnancy-related deaths worldwide. According to ESC, 68% of these deaths are preventable. Up to 4% of pregnancies are complicated by cardiovascular disease, a figure that rises to 10% when hypertensive disorders are included.
The guidelines call for personalized risk assessments for all women with cardiovascular disease, taking into account medical history, medications, lifestyle factors, age, body mass index, smoking status, and socioeconomic background. Maternal preferences must also be central to decision-making.
For adolescents with congenital or inherited heart disease, the ESC advises early discussions about pregnancy risks starting at puberty, citing high rates of unintended pregnancies in this group.
Updates also address medication use during pregnancy, encouraging the continuation of some treatments, including statins in selected cases, and providing revised recommendations for hypertension and cardiogenetic disorders. “Pregnant women are often at risk of receiving sub-optimal treatment due to limited data. Our guidelines aim to ensure essential therapies are not withheld unnecessarily,” said Professor Haugaa.
A major emphasis is placed on Pregnancy Heart Teams—specialized, multidisciplinary groups that support women before, during, and after pregnancy. These teams have been shown to reduce maternal deaths, hospital readmissions, and safety risks. The ESC recommends establishing such teams in specialist centers, tailored to local needs.
Additional recommendations include:
Clearer criteria for cesarean sections, noting that unnecessary procedures may increase fetal risk.
Postponing pregnancy for at least one year after heart transplantation.
Providing more nuanced risk assessments based on new evidence.
The 2025 guidelines, endorsed by the European Society of Gynecology, replace the 2018 edition and underscore the unique challenges pregnancy poses for women with heart disease. Physiological changes during pregnancy—such as a 30%–50% increase in cardiac output and a rise in heart rate—can overwhelm the compromised cardiovascular systems of affected women, leading to complications including heart failure and arrhythmias.
YOU MAY ALSO LIKE
ESC Updates Pregnancy Guidelines, Emphasizes Women’s Autonomy
ESC Issues New Lipid Management Guidelines to Cut Heart Risk
