Cardiovascular Disease and Hypertension in Pregnancy – 2025 ESC Guidance
Cardiovascular Disease and Hypertension in Pregnancy – 2025 ESC Guidance
Source: 2025 ESC Guidelines on Cardiovascular Disease and Pregnancy; ESC Focused Updates on Hypertension in Pregnancy
1. Shift in Philosophy
• The new 2025 ESC guidelines no longer advise all high-risk women to “avoid pregnancy” categorically.
• Instead, emphasis is on personalized, multidisciplinary care with Pregnancy Heart Teams (cardiologists, obstetricians, anesthesiologists, geneticists, and mental health specialists).
• Women’s autonomy is highlighted, ensuring shared decision-making and tailored counseling.
2. Safe and Commonly Used Medications in Pregnancy
• Antihypertensives:
• Labetalol (oral or IV).
• Methyldopa.
• Nifedipine (extended release).
• Other key drugs:
• Low-dose aspirin → for preeclampsia prevention in high-risk women.
• Heparins (LMWH, UFH) → preferred anticoagulants during pregnancy.
3. Second- to Fifth-Line Antihypertensives
• Second-line:
• Hydralazine (oral or IV), particularly in severe hypertension.
• Third-line:
• Other calcium channel blockers (e.g., amlodipine) – safety data growing.
• Beta-blockers other than labetalol (e.g., metoprolol, propranolol) – generally safe.
• Avoid atenolol (risk of fetal growth restriction).
• Fourth-line (specialist use, case-by-case):
• Clonidine – limited evidence, more side effects.
• Thiazide diuretics – may be continued if pre-pregnancy use, but not first choice.
• Fifth-line / Rescue therapies (life-threatening only):
• IV nitroglycerin (e.g., pulmonary edema in preeclampsia).
• Sodium nitroprusside – only for very short duration (risk of cyanide toxicity).
4. Contraindicated in Pregnancy
• Teratogenic agents:
• ACE inhibitors, ARBs, ARNIs, direct renin inhibitors.
• Hormonal/anti-androgenic risks:
• Spironolactone, eplerenone.
• Beta-blocker specific:
• Atenolol → linked to fetal growth restriction.
• Lipid therapies:
• Statins generally avoided (though data evolving).
• Anticoagulants:
• Warfarin → risk of embryopathy (except selected mechanical valve cases with risk-benefit discussion).
5. Special Notes from ESC 2025
• Heart transplantation: Postpone pregnancy for ≥1 year after transplant.
• Cesarean section: Considered in select high-risk cardiovascular cases.
• Case-by-case therapies: Certain lipid and cardiogenetic drugs may be considered under specialist guidance.
