2025 ESC Cardiovascular Disease and Pregnancy Guidelines — Quick Reference

What's New in 2025

The 2025 ESC Guidelines represent a major update since 2018, incorporating expanded guidance on the Pregnancy Heart Team, updated mWHO 2.0 risk stratification, refined medication recommendations, algorithms for clinical management, new sections on peripartum cardiomyopathy and aortopathies, and increased focus on adverse pregnancy outcomes and long-term cardiovascular health.

Key Structural Changes

Dedicated section on Pregnancy Heart Team multidisciplinary management
Refined mWHO 2.0 classification with expanded clinical categories
Integrated algorithms for management of clinical scenarios (e.g., anticoagulation, arrhythmias, delivery)
New emphasis on adverse pregnancy outcomes (APOs) and long-term cardiovascular risk
Enhanced guidance on genetic testing, assisted reproductive technology, and contraception

Cardiovascular Physiology in Pregnancy

Pregnancy induces profound hemodynamic changes to meet increased metabolic demands of mother and fetus. Understanding these adaptations is essential for risk stratification and management.

Hemodynamic Changes

Plasma volume: Increases 40% by 2nd–3rd trimester
Cardiac output: Increases 30–50% (peaked at 23–31 weeks); returns to baseline ~6 weeks post-partum
Heart rate: Increases 10–20 bpm
Systemic vascular resistance: Decreases 20–50% (due to increased progesterone and nitric oxide)
Blood pressure: Systolic and diastolic BP drop by ~15–25% above baseline; nadir at ~20 weeks gestation

ECG Changes

PR interval shortened
T-wave flattening or inversion in leads III, aVF, V1–V2
Prominent Q waves in III, aVF (physiological Q waves, not pathological)
Small ST-segment depressions

Echocardiographic Changes

LA size: Slightly increased
LVEDD: Small increase
LVEF: Unchanged (normal systolic function preserved)
RVEF: Usually normal
Systolic pulmonary artery pressure (SPAP): Unchanged
Pericardial effusion: Small effusions common (no pathological significance)

Pre-Pregnancy Risk Assessment: Modified WHO 2.0 Classification

All women with CVD should be risk-stratified using mWHO 2.0 classification. Risk categories determine counseling, medication adjustments, monitoring intensity, and delivery planning.

mWHO Category	Risk Level	Examples	Pregnancy Heart Team
Class I	Minimal risk	Uncomplicated native valve disease, corrected simple lesions, mild LV dysfunction	Regular healthcare professional
Class II	Small increased risk	Unrepaired ASD/VSD, moderate LV dysfunction, repaired cyanotic heart disease	Regular professional + specialist consultation
Class II-III	Intermediate risk	Mechanical valves, moderate–severe LV outflow obstruction, PAH, Marfan syndrome	Expert counseling by Pregnancy Heart Team required
Class III	High risk	Severe LV dysfunction, severe aortic stenosis, uncontrolled arrhythmias, systemic RV	Expert Pregnancy Heart Team required; shared decision-making
Class IV	Very high/prohibitive risk	Severe aortic dissection, unrepaired cyanotic heart disease, peripartum cardiomyopathy in prior pregnancy with LV dysfunction	Expert Pregnancy Heart Team; pregnancy contraindicated

CARPREG II Score

Quantifies maternal adverse cardiac event (MACE) risk during pregnancy. Scores ≥2 (2 points) indicate intermediate risk; ≥4 (3 points) indicate higher risk. Shared decision-making essential for Class III–IV.

Medication Safety in Pregnancy: Do's and Don'ts

Safe Antihypertensives

Preferred Agents (All Trimesters)

Labetalol: 200–2400 mg daily (divided 2–3×/day); preferred first-line
Methyldopa: 500–2000 mg daily (divided 2–3×/day)
Nifedipine (extended-release): 30–120 mg daily; immediate-release safe for acute HTN
Hydralazine: For severe HTN (IV 5–10 mg bolus); lupus-like syndrome risk with prolonged use

Contraindicated Agents

ACE inhibitors: All trimesters (teratogenic; renal dysgenesis, oligohydramnios, IUGR)
Angiotensin receptor blockers (ARBs): Similar teratogenic risk to ACEi
Atenolol: Associated with fetal growth restriction (use labetalol instead)
Thiazide diuretics: Limited use; avoid for routine HTN (electrolyte disturbances)

Anticoagulation (VTE & Mechanical Valves)

Indication	1st Trimester	2nd/3rd Trimester	Post-partum
Mechanical valves	VKA (warfarin) INR 2–3 or LMWH dose-adjusted	Continue VKA; weekly INR checks	Switch to VKA; INR 2–3; resume post-partum
VTE (treatment)	LMWH therapeutic dose (SC)	LMWH or UFH IV	LMWH/UFH → warfarin 7–14 days
VTE (prophylaxis)	LMWH prophylactic dose	LMWH prophylactic dose	Continue LMWH; consider warfarin

Contraindicated Anticoagulants

Warfarin (1st trimester): Fetal warfarin syndrome (nasal hypoplasia, bone dysplasia, CNS abnormalities)
DOACs: Insufficient safety data; avoid in pregnancy
Unfractionated heparin (UFH, long-term): Osteoporosis, thrombocytopenia risk; use UFH only peripartum or if mechanical valve with high thrombosis risk

Lipid-Lowering & Other Agents

Contraindicated Agents

Statins: Insufficient safety data; stop pre-conception
Ezetimibe, PCSK9i: Avoid; limited evidence
Myosin inhibitors: Contraindicated; teratogenic
Amiodarone: Class IIb only if essential (fetal hypothyroidism, IUGR); avoid 1st trimester

Hypertensive Disorders in Pregnancy

Classification

Pre-existing (chronic) hypertension: BP ≥140/90 before pregnancy or 1st trimester
Gestational hypertension: BP ≥140/90 after 20 weeks; no proteinuria or organ dysfunction; resolves ≤6 weeks post-partum
Pre-eclampsia: Gestational HTN + proteinuria (≥0.3 g/24 h) or ≥1 organ dysfunction feature (Lab: thrombocytopenia, liver/renal dysfunction; Clinical: severe HTN, severe symptoms)
Severe hypertension: BP ≥160/110 mmHg

Management by BP Level

Non-severe HTN (140–159/90–109 mmHg)

Non-pharmacological: Salt restriction, weight control, bed rest, stress reduction

Pharmacological: Initiate labetalol, nifedipine (extended-release), or methyldopa

Target: <140/90 mmHg; avoid overcorrection (placental hypoperfusion)

Severe HTN (≥160/110 mmHg)

Hospitalization required

Acute therapy: IV labetalol 20 mg, then 40–80 mg q 10 min (max 220 mg), OR IV hydralazine 5–10 mg q 20 min (max 20 mg)

Oral step-down: Labetalol 200 mg TID, nifedipine ER 30 mg daily, or methyldopa 500 mg TID

Continuous monitoring; eclampsia prevention (magnesium sulfate if seizures/HELLP)

Pre-eclampsia Prophylaxis

Class I Level A Aspirin 75–150 mg daily from 12 weeks to delivery for women with ≥1 moderate-risk factor for pre-eclampsia.

Blood Pressure Targets

Non-severe HTN: <140/90 mmHg (avoid <130/80; increased stillbirth risk)
Pre-eclampsia: <140/90 mmHg (if <160/110; hospitalize if ≥160/110)
Post-partum: Monitor for new-onset or worsening HTN; adjust medications post-delivery

Valvular Heart Disease in Pregnancy

Mechanical Valves: The Anticoagulation Dilemma

Pregnant women with mechanical heart valves face triple jeopardy: thromboembolism from valve + physiological hypercoagulability + teratogenic anticoagulants. Management requires individualized shared decision-making.

Trimester	Preferred Strategy	INR Target / Dosing	Monitoring
1st trimester	Warfarin (VKA) OR LMWH dose-adjusted	INR 2–3 (warfarin); LMWH peak Xa 0.6–1.2 mU/mL	Weekly INR or Xa levels
2nd/3rd tri	Warfarin (preferred) or continue LMWH	INR 2–3; LMWH adjusted dosing	INR weekly; Xa levels every 2–4 weeks
36 weeks–delivery	Switch to UFH (IV or SC)	aPTT 1.5–2× control (therapeutic)	aPTT daily or q 2–3 days
Post-partum	Resume warfarin or LMWH; breastfeeding safe	INR 2–3 (7–14 days post-delivery)	INR check; safe for breastfeeding

Pearl: LMWH (especially if dose-adjusted) carries higher valve thrombosis risk than warfarin in pregnancy. Warfarin is preferred 2nd/3rd trimester for mechanical valves, despite 1st trimester teratogenicity risk. Shared decision-making is essential.

Native Valve Disease

Mild stenosis/regurgitation: Usually well tolerated; counsel on activity limitation, treat any HTN/AF
Moderate–severe: Consider valve intervention (balloon, surgical repair) pre-pregnancy if high-risk features (low CO, large LA, AF, thrombus)
Regurgitation: Generally better tolerated than stenosis; avoid excessive fluid overload

Cardiomyopathy in Pregnancy

Peripartum Cardiomyopathy (PPCM)

Definition: LVEF <45% without other explainable cause, occurring during peripartum period or <6 months post-delivery.

Incidence: 1 per 3000–4000 pregnancies globally; higher in Africa, North America
Risk factors: Multiparity, older age, pre-eclampsia, diabetes, smoking, fertility treatments, genetic variants
Outcomes: 25–60% recover LVEF by 6 months; worse outcomes in developing countries, Black women; mortality ~1%

Management

Pregnancy

Standard HF medications, with modifications: ACEi/ARB avoid (teratogenic); use labetalol, nifedipine for HTN

Close monitoring for symptoms, echocardiography q 6–8 weeks

Consider vasodilator therapy (ARNi, ACEi post-partum) after delivery

Post-partum

Bromocriptine 2.5 mg daily × 1 week or 5 mg daily × 2 weeks (Class IIb pregnancy, Class IIa post-partum) to reduce thrombosis/HF progression

Initiate full HF GDMT: ACEi/ARB, beta-blockers, MRAs, SGLT2i (once LVEF <40%)

LVAD, transplant, or MCS for severe refractory HF; ICU care if cardiogenic shock

Other Cardiomyopathies (DCM, HCM, ARVC)

Management Principles

Genetic counseling & testing before pregnancy
Pre-pregnancy risk assessment; optimize LVEF & arrhythmia control
Medications: Beta-blockers continue (good pregnancy safety); ACEi/ARB avoided (switch to labetalol); SGLT2i avoided (limited data)
Echocardiography q 8–12 weeks; ECG monitoring if arrhythmia history
ICD considerations: Device function checked pre-delivery; can remain in-situ; fetal monitoring post-implant

Arrhythmias in Pregnancy

Safe Antiarrhythmic Agents

First-Line Options

Adenosine (6–18 mg IV bolus): Safest for acute SVT termination (Class I); no fetal effects; rapid action
Beta-blockers (labetalol, metoprolol): Vagal maneuvers preferred for SVT; beta-blockers for rate control AF/SVT
Flecainide: SVT prevention, AF rhythm control; bidirectional activity; monitor QTc
Digoxin: Rate control (especially Fontan circulation); monitor levels; fetal safe
Sotalol: AF/SVT; also beta-blocking; prolong QTc—monitor ECG
Verapamil (IV): SVT termination (Class IIa); avoid in HF or RV dysfunction

Agents to Avoid or Use with Extreme Caution

Amiodarone: Class IIb if no alternative; fetal hypothyroidism, IUGR, prematurity risk; considered only in refractory VT/VF
Dofetilide, sotalol (high-dose): QT prolongation; torsades risk
ACEi/ARB: Contraindicated (teratogenic)

Specific Arrhythmias

Supraventricular Tachycardia (SVT)

Acute management: Vagal maneuvers (Valsalva), adenosine 6–18 mg IV (Class I), electrical cardioversion if unstable
Rate control: Beta-blockers (metoprolol, labetalol) or verapamil; avoid atenolol
Prophylaxis: Continue pre-pregnancy beta-blockers; flecainide if frequent episodes

Atrial Fibrillation & Flutter (AF/AFL)

Rate control: IV beta-blockers (metoprolol) or digoxin (Class I); verapamil alternative
Rhythm control: Flecainide (Class I for paroxysmal AF), sotalol, or digoxin (for atrial flutter)
Avoid: Amiodarone (unless VT/VF with reduced EF); amiodarone contraindicated with maternal hypothyroidism, IUGR
Anticoagulation: If AF with structural heart disease → LMWH or VKA; assess CHADS₂VASc score

Ventricular Arrhythmias (VT/VF)

Acute: Electrical cardioversion (Class I, safe all trimesters), IV lidocaine (Class I), IV magnesium if Torsades
Chronic VT (inherited syndromes, cardiomyopathy): Beta-blockers, flecainide, sotalol; ICD management pre-planned
Avoid: Class IA agents (quinidine, procainamide); amiodarone only if VF unresponsive to other measures

Primary Arrhythmia Syndromes

Long QT Syndrome

Rx: Beta-blockers (nadolol/propranolol preferred); ICD if recurrent syncope; family screening

Brugada Syndrome

Rx: Quinidine if arrhythmic events; avoid fever (avoid NSAIDs); ICD if prior syncope/VF

CPVT

Rx: Beta-blockers ± flecainide; ICD if refractory; avoid catecholamine surges

Short QT

Rx: Quinidine for prophylaxis; ICD if arrhythmic; individualized management

Congenital Heart Disease in Pregnancy

Outcomes depend on type of lesion, prior surgical repair, presence of arrhythmias, and maternal LV/RV function. Complex lesions (cyanosis, RV systemic ventricles, Eisenmenger, unrepaired ToF) carry very high maternal & fetal mortality risk.

Risk Stratification

mWHO Class I: Simple uncomplicated lesions (PDA, ASD, pulmonary stenosis); excellent outcomes
mWHO Class II: Repaired simple lesions, mild LV dysfunction, corrected ToF; generally favorable
mWHO Class III: Moderate cyanosis, significant RV dysfunction, unrepaired complex lesions; shared decision-making
mWHO Class IV: Eisenmenger syndrome, severe cyanosis, failing systemic RV, unrepaired complex cyanosis; pregnancy contraindicated

Special Lesions

Fontan circulation: Paradoxical embolism risk, AF, ventricular dysfunction; anticoagulation & close monitoring essential
ACHD (adult congenital): Assess baseline O₂ saturation, EF, arrhythmias; high-risk if cyanotic, LV dysfunction, or AF
Cyanotic heart disease: Target O₂ sat >85%; avoid dehydration (paradoxical embolism); blood loss replacement critical

Fetal Outcomes in Maternal Cyanotic Heart Disease

Fetal risk correlates with maternal O₂ saturation: <90% sat = ~50% fetal loss; maternal NYHA III–IV = poor outcomes; cyanosis + anticoagulation (VKA) = increased fetal risk.

Aortic Disease in Pregnancy

Aortic Root Diameter Thresholds for Prophylactic Surgery

Condition	Pre-pregnancy Aortic Root Diameter Threshold	Management
Marfan syndrome	≥45 mm (deliver if reaches this diameter)	Beta-blockers ± losartan; imaging q 4–6 weeks; deliver at 37–38 weeks if safe
Vascular EDS	Extremely high risk; diameter <25 mm still carries dissection risk	Pregnancy often contraindicated; cesarean at 36 weeks if proceed
Turner syndrome	<30 mm safe; 30–35 mm needs close monitoring	Imaging q 4–6 weeks if pregnant; beta-blockers if ≥35 mm
Bicuspid aortic valve	<50 mm safe; 40–45 mm needs monitoring & family screening	Echocardiography q 8 weeks; deliver vaginally if <45 mm, low-risk features

Management During Pregnancy

Beta-blockers (labetalol): Maintain low BP & heart rate to reduce aortic wall stress
ARBs (losartan): Added in Marfan syndrome to reduce aortic stiffness (contraindicated in pregnancy if ACEi-containing; use after delivery)
Imaging: TTE baseline, 8 weeks, 16 weeks, pre-delivery, 6 weeks post-partum
Delivery: Vaginal delivery preferred if <45 mm (Marfan) and no other high-risk features; cesarean if high dissection risk

Pitfall: Aortic dissection in pregnant women can be catastrophic. Maintain BP <140/90, avoid excessive Valsalva, NSAIDs. Consider MRI/CT only if dissection suspected (limited fetal exposure).

Coronary Artery Disease in Pregnancy

Epidemiology

ACS incidence: 3–5 times higher in pregnant vs. non-pregnant women
Pregnancy-associated SCAD: Most common cause of ACS in young pregnant women; coronary artery dissection without atherosclerotic disease
Risk factors: Hypertension, pre-eclampsia, smoking, older age (>35), diabetes, peripartum period (especially first few weeks post-partum)

Diagnosis & Management

ECG, troponin, chest X-ray: Same as non-pregnant
Coronary angiography: Performed if ACS suspected; consider SCAD diagnosis (coronary dissection, endothelial dysfunction)
PCI (percutaneous coronary intervention): Preferred over CABG in pregnancy; stent type (BMS vs DES) depends on delivery timing
Medications: Aspirin (Class I), clopidogrel if PCI (Class I), beta-blockers, avoid ACEi (switch to labetalol), statins stopped

Chronic Coronary Artery Disease in Pregnancy

Medical therapy: Aspirin, beta-blockers, nitroglycerin as needed; avoid ACEi (use labetalol)
Activity: Restrict based on symptoms; stress testing not routinely done (false positives)
Delivery: Vaginal preferred unless obstetric indication; avoid prolonged labor & excessive exertion

Venous Thromboembolism in Pregnancy & Post-partum

Epidemiology & Risk

Incidence: 1.2 per 1000 deliveries; risk highest in 3rd trimester & early post-partum (up to 12 weeks)
Risk factors: CVD, older age, obesity, immobility, hypercoagulability (pregnancy), prior VTE, thrombophilia, oral contraceptive use pre-conception
Prevention: Early mobilization, sequential compression devices (if high-risk), prophylactic LMWH

Prophylaxis & Treatment Dosing

LMWH Agent	Prophylactic Dose	Therapeutic Dose	Timing
Enoxaparin	40 mg SC daily	150 IU/kg SC daily	Throughout pregnancy & 6 weeks post-partum
Dalteparin	5000 IU SC daily	200 IU/kg SC daily	Throughout pregnancy & 6 weeks post-partum
Tinzaparin	4500 IU SC daily	175 IU/kg SC daily	Throughout pregnancy & 6 weeks post-partum

Management of Acute VTE in Pregnancy

Deep Vein Thrombosis (DVT)

Immediate: Therapeutic LMWH (weight-adjusted dose); compression ultrasound to confirm diagnosis

Ongoing: Continue LMWH throughout pregnancy; switch to UFH at 36 weeks or for urgent delivery

Post-delivery: Continue heparin or switch to warfarin (INR 2–3) 7–14 days post-partum

Pulmonary Embolism (PE)

Diagnosis: ECG (S1Q3T3 pattern rare), D-dimer elevated in pregnancy, CXR (rule-out other causes), CT angiography or V/Q scan

Treatment: Therapeutic LMWH immediately (do NOT delay for imaging if high clinical suspicion); UFH if hemodynamic instability

Consider thrombolysis (tPA) or catheter embolectomy if massive PE with shock

Anticoagulation Management Around Delivery

At 36 weeks: Switch from LMWH to UFH (continuous IV or SC BID)
Before labor: Discontinue UFH at labor onset; restart post-delivery
After vaginal delivery: Restart UFH or LMWH; transition to warfarin 7–14 days post-partum
After cesarean section: Continue heparin; warfarin transition as above

Delivery Planning & Hemodynamic Management

Timing of Delivery

Spontaneous labor: Preferred; most women with CVD achieve full-term delivery (37 weeks)
Indicated early delivery (<37 weeks): Maternal CVD decompensation, severe pre-eclampsia, fetal distress
Induction of labor: Consider at 39 weeks if high obstetric/cardiac risk (e.g., mechanical valve, severe aortic stenosis)

Mode of Delivery

Vaginal Delivery (Preferred)

Recommended in most CVD conditions (Class I, Level B)
Lower blood loss, shorter hospitalization, faster recovery
Pain relief essential (epidural or spinal anesthesia preferred)

Cesarean Section Preferred For

Severe aortic stenosis (>50 mmHg gradient)
Left ventricular outflow tract obstruction (LVOTO) with symptoms
Uncontrolled arrhythmias, NYHA III–IV, reduced EF, heart transplant
Obstetric indications (fail to progress, fetal distress, malpresentation)

Hemodynamic Monitoring

Continuous ECG, BP, pulse oximetry: Baseline monitoring for all CVD women
Arterial line: Consider for severe valve disease, systemic RV, post-transplant, cardiogenic shock risk
Central venous catheter: Only if monitoring RV filling (RV dysfunction, LVOTO)
Goal: Maintain euvolemia; avoid hypotension (placental insufficiency) & fluid overload (pulmonary edema)

Anesthesia Considerations

Epidural preferred: Gradual sympathetic blockade; safer than spinal (rapid sympathetic loss)
Avoid: Volatile anesthetics (myocardial depression), rapid fluid boluses, sudden sympathomimetics
Pain relief essential: Reduces catecholamine surge, myocardial ischemia risk
Magnesium: For eclampsia seizure prophylaxis in pre-eclampsia

Anticoagulation Management During Delivery

VKA-Treated (Mechanical Valves)

Discontinue VKA at 36 weeks; switch to therapeutic UFH or LMWH

At labor onset: Discontinue UFH 4–6 h before delivery; assess aPTT

Post-delivery: Restart heparin (UFH or LMWH); transition to warfarin 7–14 days

LMWH-Treated (VTE)

Discontinue LMWH at 36 weeks; switch to UFH (IV or SC)

At labor: Stop UFH 4–6 h before; ensure aPTT therapeutic (1.5–2.5×)

Post-delivery: Restart LMWH or UFH; warfarin at 7–14 days

Post-partum Care & Complications

Monitoring (First 48 Hours)

Hemodynamic monitoring: Continuous ECG, BP, pulse oximetry (especially high-risk women)
Fluid balance: Careful input/output; avoid rapid fluid shifts (triggers HF)
Medications: Restart/adjust cardiovascular medications post-delivery
Thromboembolism risk: VTE prophylaxis; early mobilization; compression devices if immobile

Breastfeeding & Lactation Safety

Safe Medications for Breastfeeding

Beta-blockers (labetalol, metoprolol preferred)
ACE inhibitors & ARBs (post-partum)
Digoxin, warfarin, aspirin
LMWH (not absorbed orally)
Diuretics (unless excessive dosing → ↓ milk supply)

Agents Requiring Caution or Avoidance

Lithium (high infant dose; neonatal toxicity)
Amiodarone (fetal thyroid concerns; relative infant dose high)
ACEi/ARB in 1st trimester if planning future pregnancy (wait 6 months post-partum)

Common Post-partum Complications

Post-partum Hemorrhage (PPH)

Risk: Up to 5× higher in women with pre-existing CVD
Prevention: Early 3rd stage active management (oxytocin 10 IU IM after delivery)
Avoid: Ergot alkaloids (ergot, methylergonovine) → hypertension, coronary vasoconstriction
Treatment: IV oxytocin, blood transfusion, uterine compression, embolization if severe

Post-partum Pre-eclampsia & Hypertension

Incidence: 5–25% of pregnancies with pre-eclampsia develop post-partum HTN
Treatment: Same agents as pregnancy (labetalol, nifedipine, methyldopa); ACEi/ARB post-delivery
Magnesium: Continue for seizure prophylaxis if eclampsia risk

Post-partum Depression & Mental Health

Risk: 10–20% in general population; 15–30% in women with CVD
Screening: Edinburgh Postnatal Depression Scale at 2 weeks & 6–8 weeks post-partum
Treatment: Psychotherapy, SSRIs (safe breastfeeding), supportive care

Long-term Post-partum Follow-up

Cardiovascular risk assessment: BP, glucose, lipids, BMI; assess for diabetes, HTN
Women's Heart Clinic: Multidisciplinary follow-up (cardiologist, primary care, mental health) to integrate CVD & Women's health
Adverse pregnancy outcomes (APOs): Pre-eclampsia, gestational diabetes, prematurity, IUGR → increased future cardiovascular risk; preventive interventions needed

Contraception in Women with Cardiovascular Disease

Recommended Methods

Safe Options

Progestin-only pills (POPs): No VTE/HTN risk; ideal for mWHO Class II–III (with caution)
Levonorgestrel IUD: Safest & most effective; no systemic absorption; recommended first-line
Copper IUD: No cardiovascular risk; excellent efficacy; allows backup barrier methods
Barrier methods: Condoms, diaphragm; requires consistent use; acceptable combined with IUD
Tubal ligation/vasectomy: Permanent; no CV risk; consider for mWHO Class III–IV

Contraindicated or Requires Caution

Combined oral contraceptives (estrogen-containing): VTE risk ↑ 2–4×; HTN risk; avoid mWHO ≥II
Estrogen patch, vaginal ring: Similar CV risks to oral; avoid mWHO ≥II
Copper IUD + PAH: Insertion risk (pelvic infection); consider after hysterectomy or stable case

mWHO Class-Specific Guidance

Class I: All contraceptive methods acceptable; IUD preferred for efficacy
Class II: Progestin-only or IUD preferred; combined OCP requires careful assessment
Class III: Progestin-only, IUD, permanent methods strongly recommended; avoid estrogen
Class IV: Permanent sterilization or long-acting reversible contraception (LARC) strongly recommended; pregnancy contraindicated

Clinical Do's and Don'ts

DO:

Perform risk assessment in ALL women with CVD (mWHO 2.0 classification)
Establish a Pregnancy Heart Team for mWHO Class III–IV
Counsel on pregnancy risks, medication safety, and contraception pre-conception
Use beta-blockers, labetalol, nifedipine for hypertension & arrhythmia control
Perform echocardiography at baseline, 2nd trimester, 3rd trimester, & 6 weeks post-partum if high-risk
Prefer vaginal delivery unless high cardiac risk or obstetric indication
Monitor hemodynamics closely during labor & immediately post-partum
Use aspirin prophylaxis for pre-eclampsia prevention (≥1 risk factor)
Switch from VKA → LMWH or UFH at 36 weeks (mechanical valves) or upon labor onset
Encourage breastfeeding with appropriate medication management
Recommend long-acting reversible contraception (IUD, implant) or permanent sterilization for high-risk women

DON'T:

Use ACE inhibitors, ARBs, or statins during pregnancy (teratogenic/insufficient safety data)
Use warfarin in 1st trimester (fetal warfarin syndrome); switch to LMWH or UFH
Prescribe DOACs in pregnancy (insufficient safety data)
Use amiodarone unless life-threatening VT/VF unresponsive to other agents
Prescribe combined oral contraceptives in mWHO Class II–IV (VTE risk)
Forget to screen for adverse pregnancy outcomes (pre-eclampsia, GDM, prematurity) → future CVD risk
Avoid vaginal delivery without obstetric indication (cesarean increases morbidity)
Withhold anticoagulation in mechanical valve patients during pregnancy (thrombosis risk)
Use ergot alkaloids for PPH prevention (hypertensive crisis, coronary vasospasm)
Defer counseling about genetic transmission of inherited CVD (affects future pregnancies, family members)

Clinical Decision-Support Calculators

Integrated calculator tools to support risk assessment, medication dosing, and clinical decision-making in pregnant and post-partum women with cardiovascular disease.