#JustReleased ESC 2018 Guidelines for Management of CVDs Dur

2018 ESC Guidelines for Management of CVDs During Pregnancy

The European Society of Cardiology (ESC) has recently released updated recommendations for the management of cardiovascular diseases (CVDs) during pregnancy. The guidance document has been published in the European Heart Journal and replaces the one released in 2012.

“Knowledge of the risks associated with CVDs during pregnancy and their management in pregnant women who suffer from serious pre-existing conditions is of pivotal importance for advising patients before pregnancy. Since all measures concern not only the mother but the foetus as well, the optimum treatment of both must be targeted. A therapy favourable for the mother can be associated with potential harm to the developing child and, in extreme cases, treatment measures that protect the survival of the mother can cause the death of the foetus. On the other hand, therapies to protect the child may lead to a suboptimal outcome for the mother” the authors write.

Predictors of maternal and neonatal events

Some of the key recommendations are:-

A. General Recommendations
• Pre-pregnancy risk assessment and counselling is indicated in all women with known or suspected congenital or acquired cardiovascular and aortic disease
• Treat high risk patients in specialized centres by a multidisciplinary team: the pregnancy heart team
• Echocardiography is recommended in any pregnant patient with unexplained or new cardiovascular signs or symptoms
• Vaginal delivery is recommended as first choice in most patients

B. Pregnancy and pulmonary hypertension or congenital heart disease 
• Right heart catheterization is recommended to confirm the diagnosis of pulmonary arterial hypertension (PAH). This can be performed during pregnancy but with very strict indications, optimal timing, and shielding of the foetus
• Pregnancy is not recommended in patients with PAH

C. Management of aortic disease 
• Imaging of the entire aorta (CT/MRI) before pregnancy in patients with a genetically proven aortic syndrome or known aortic disease
• When a woman with known aortic dilatation, (history of) dissection, or genetic predisposition for dissection becomes pregnant, strict blood pressure control is recommended
• Repeated echocardiographic imaging every 4–12 weeks (depending on the diagnosis and severity of dilatation) during pregnancy and 6 months post-partum in pts with ascending aorta dilatation
• In patients with an ascending aorta <40 mm, vaginal delivery is recommended
• Pregnancy is not recommended in patients with vascular Ehlers–Danlos syndrome

D. Management of prosthetic heart valves 
• Choose the valve prosthesis in women contemplating pregnancy in consultation with a pregnancy heart team
• If delivery starts while on VKA or in less than 2 weeks after discontinuation of a VKA, caesarean section is indicated
• Discontinue VKA and start adjusted-dose intravenous UFH (aPTT ≥control) or adjusted-dose LMWH at the 36th week of gestation

E. Management of hypertension 
• Low-dose aspirin (100–150 mg daily) in women at high or moderate risk of pre-eclampsia from week 12 to week 36-37
• In women with gestational hypertension or pre-existing hypertension superimposed by gestational hypertension, or with hypertension and subclinical organ damage or symptoms, initiation of drug treatment is recommended at SBP >140 mmHg or DBP >90 mmHg In all other cases, initiation of drug treatment is recommended at SBP ≥150 mmHg or DBP ≥95 mmHg
• SBP ≥170 mmHg or DBP ≥110 mmHg in a pregnant woman is an emergency, and hospitalization is recommended
• Methyldopa, labetalol, and calcium antagonists are the drugs of choice for the treatment of hypertension in pregnancy
• It is recommended to expedite delivery in pre-eclampsia, and with adverse conditions such as visual disturbances or haemostatic disorders
• In severe hypertension, drug treatment with intravenous labetalol, oral methyldopa, or nifedipine is recommended

F. Cardiomyopathies and heart failure
• Anticoagulation in pts with intracardiac thrombus detected by imaging or with evidence of systemic embolism
• Treat women with heart failure during pregnancy according to current guidelines for non-pregnant patients, respecting contraindications for some drugs in pregnancy
• Inform women with HFrEF (heart failure with reduced ejection fraction) about the risk of deterioration of the condition during gestation and peripartum
• Therapeutic anticoagulation with LMWH or VKAs according to stage of pregnancy is recommended for patients with AF.
• In HFrEF, it is recommended that beta-blockers are continued in women who used them before pregnancy, or that they are installed with caution if symptoms persist

About ESC
The European Society of Cardiology (ESC) is a non-profit knowledge-based professional association that facilitates the improvement and harmonization of standards of diagnosis and treatment of cardiovascular diseases. The ESC produces, organizes and supports many scientific and educational activities and products aimed at cardiology professionals wishing to increase their knowledge and update their skills. The ESC was founded in 1950 and its headquarters are located in Sophia Antipolis in the South of France.

Note: This list is a brief compilation of some of the key recommendations included in the guidelines and is not exhaustive and does not constitute medical advice. Kindly refer to the original publication here: https://pxmd.co/HbSXR

About Author
Dr. Prachi Chhimwal
Dr. Prachi Chhimwal is an Editor at PlexusMD and is a part of the Engagment Team. She curates the Technical Content posted daily on the news feed. She graduated from Army College of Dental Sciences (B.D.S) and went on to pursue her post-graduation (M.D.S) in Oral & Maxillofacial Pathology. After a decade in the field of dentistry she took a leap of faith and joined PlexusMD. A badminton enthusiast, when not working you can find her reading, Netflixing or enjoying stand-up comedy shows.
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