New ESC guidelines on management of CVD during pregnancy
The European Society of Cardiology (ESC) published new guidelines on management of cardiovascular disease (CVD) during pregnancy, which are also endorsed by the International Society of Gender Medicine, the German Institute of Gender in Medicine, the European Society of Anesthesiology, and the European Society of Gynecology. Revision of the guidelines published in 2012 was necessary since new evidence has accumulated on diagnostic techniques, risk assessment and the use of CV drugs.
In about 1-4% of pregnancies, it is complicated by maternal disease. Since all measures concern both mother and fetus, the optimum treatment of both must be targeted. What is good for one, may be harmful for the other.
A task force, selected by the ESC, representing professionals involved in the medical care of patients with specific pathology, undertook a comprehensive review of the published evidence for management of CVD during pregnancy and critically evaluated diagnostic and therapeutic procedures, including assessment of risk-benefit ratio. Prospective or randomized studies are often lacking, which is the reason why most recommendations in these guidelines correspond to evidence level C. The format of these guidelines has been adapted to facilitate their use in clinical practice, with clearly presented recommendations at the end of each section. Revised and new recommendations on management of CVD during pregnancy are briefly summarized below.
The new guidelines recommend performing risk assessment in all women with cardiac disease of childbearing age and before conception, using the modified World Health Organization (mWHO) classification of maternal risk (class of recommendation I, level of evidence C). It should be considered to induce labour at 40 weeks gestation in all women with cardiac disease (IIa C).
Congenital heart disease and pulmonary hypertension
To confirm the diagnosis of pulmonary arterial hypertension (PAH), right heart catherization is recommended, which can be performed during pregnancy with very strict indications (I C). Low molecular weight heparin (LMWH) in therapeutic dose is recommended in pregnant patients with chronic thrombo-embolic pulmonary hypertension (I C). In treatment-naïve pregnant PAH patients, initiation of treatment should be considered (IIa C).
Pregnancy is not recommended in patients with severe dilatation of the aorta (heritable thoracic aortic disease such as Marfan syndrome <45 mm, bicuspid aortic valve <50 mm, >27 mm/m2 BSA, or Turner syndrome ASI >25 mm/m2 BSA) (III C). In patients with (history of) aortic dissection, caesarean delivery should be considered (IIa C). Beta-blocker therapy throughout pregnancy should be considered in women with Marfan syndrome and other heritable thoracic aortic diseases (IIa C). Pregnancy is not recommended in patients with vascular Ehlers-Danlos syndrome (III C).
Valvular heart disease
In patients with mitral stenosis (MS) and valve area <1.0 cm2 intervention is recommended before pregnancy (I C). During the second and third trimesters until the 36th week, vitamin K antagonists (VKAs) are recommended in women needing a low dose (low-dose VKA: warfarin <5 mg/day, phenprocoumon <3 mg/day, or acenocoumarol <2 mg/day) (I C). It is recommended to perform weekly anti-Xa level monitoring or aPTT monitoring with dose adjustment in patients on LMWH or unfractioned heparin (UFH) (I C). In women considering pregnancy and requiring heart valve surgery, it is recommended to choose the prosthesis in consultation with a pregnancy heart team (I C). Pregnancy should be managed in women with mechanical heart valves in a center with a pregnancy heart team (I C).
Cardiomyopathies and heart failure
In patients with peripartum cardiomyopathy (PPCM), bromocriptine treatment may be considered to stop lactation and enhance recovery (IIb B).
Flecainide or propafenone are recommended for prevention of supraventricular tachycardia (SVT) in patients with WPW syndrome (I C). Catheter ablation with electroanatomical systems should be considered in experienced centers in case of drug-refractory and poorly tolerated SVT (IIa C).
Venous thrombo-embolic disease during pregnancy and the puerperium
For prevention and treatment of venous thrombo-embolism (VTE), it is recommended to treat pregnant patients with LMWH with a dose based on body weight (I C). Magnetic resonance venography should be considered in the diagnosis of VTE if compression ultrasound is negative (IIa C). In patients with pulmonary embolism, thrombolytic therapy is recommended only in severe hypotension or shock (I C). In women at high risk for thrombo-embolism, it is recommended to convert LMWH to UFH at least 36 h prior to delivery and stop the UFH infusion 4-6 h prior to anticipated delivery, aPTT should be normal before regional anesthesia (I C). In women at low risk for thrombo-embolism on LMWH therapy, it is recommended to induce caesarean section 24 h after the last dose of LMWH (I C).
Drugs during pregnancy and breastfeeding
It is no longer recommended to make decisions based on formed FDA categories (III C). Breastfeeding is not recommended in mothers who take antiplatelet agents other than low-dose aspirin (III C).