New ESC Guidelines Emphasize Women's Autonomy in Managing High-Risk Pregnancies

The latest guidelines from the European Society of Cardiology (ESC), published at the 2025 ESC Congress and featured in the European Heart Journal, mark a significant shift towards prioritizing women’s autonomy in making reproductive choices during high-risk pregnancies. These updated recommendations promote transparent dialogue, shared decision-making, and comprehensive counseling, moving away from previous advice that discouraged women with certain health conditions from pregnancy.

The guidelines advocate for multidisciplinary teams to inform women about their specific risks, considering genetic background, family history, and previous vascular events. This approach aims to empower women, especially those with cardiovascular diseases, which now constitute the leading cause of non-obstetric maternal mortality globally, accounting for 33% of pregnancy-related deaths. Notably, 68% of these deaths are preventable.

Women with conditions such as vascular Ehlers-Danlos syndrome and pulmonary arterial hypertension are no longer advised against pregnancy solely based on their risk factors. Instead, tailored counseling and personalized risk assessments are emphasized, including evaluations of maternal age, smoking history, comorbidities, BMI, obstetric history, and socio-economic factors.

The guidelines underscore the importance of maternal preferences in decision-making and recommend early discussions about pregnancy risks, starting from puberty for young women with congenital or inherited heart conditions. Additionally, updates include guidance on medication management during pregnancy, like continued use of statins for some women and revised protocols for hypertension treatment.

A key component of these guidelines is the role of specialized Pregnancy Heart Teams which support women both physically and mentally throughout pregnancy. Institutionalized teams in hospitals are essential for ensuring appropriate referrals and optimized care, ultimately reducing maternal mortality and improving safety.

Further enhancements involve clearer directives on cesarean section indications, recommended waiting periods after heart transplants, and nuanced risk assessments based on latest data. These guidelines, endorsed by the European Society of Gynecology, replace the 2018 version and aim to improve outcomes for pregnant women with cardiovascular conditions by fostering informed, shared choices and comprehensive care.

Pregnancy remains a high-risk period for women with cardiovascular disease due to physiological changes like increased cardiac output and heart rate, which can trigger complications if the heart's adaptations are faulty. The updated ESC guidance emphasizes the importance of individualized care plans to navigate these risks effectively.