HMN 2025: How Updated guidelines put focus on women’s autonomy to make their own reproductive choices about high-risk pregnancies

Updated ESC Guidelines, published at ESC Congress 2025 and featured in the European Heart Journal, put a focus on a woman’s autonomy in making her own reproductive choices by promoting transparent dialogue and shared decision-making for pregnancies that are high-risk of an adverse maternal and/or fetal event.

The guidance moves away from advising women with rare health conditions that make their pregnancy high-risk (such as vascular Ehlers-Danlos syndrome and pulmonary arterial hypertension) against pregnancy.

Instead, the guidelines recommend that women should receive counseling about the high-risk nature of their pregnancy by a multidisciplinary team, which takes into consideration their genetic background (if applicable), family history and previous vascular events.

The updated ESC Guidelines have been produced by an international panel of experts that includes co-Chairpersons, Professor Julie De Backer, Cardiologist and Clinical Geneticist from the Department of Internal Medicine and Pediatrics at Ghent University and Professor Kristina Hermann Haugaa, Cardiologist and Head of the Outpatient Clinic and Unit for Genetic Cardiac Diseases at Dept of Cardiology, Oslo University Hospital and University of Oslo.

Professor Julie De Backer explained, “More women with a history of cardiovascular disease are considering pregnancy. This is for many reasons, such as more women who were born with heart conditions are surviving to adulthood, a greater number of women who have had a transplant or cancer treatment, and more women with acquired heart disease. This guidance gives clinicians and patients clear and accessible advice based on the latest evidence.”

“In our updated guidance, we have shifted away from a rigid ‘pregnancy is forbidden’ policy in high-risk cases to a model of shared decision-making, allowing women to make fully informed choices with appropriate psychosocial support,” Professor De Backer added.

Maternal cardiovascular disease is now the leading cause of non-obstetric mortality in pregnant women, accounting for 33% of pregnancy-related deaths worldwide, and 68% of pregnancy-related deaths caused by cardiovascular disease are preventable.

Up to 4% of pregnancies are complicated by cardiovascular disease globally, rising to 10% when including high blood pressure disorders. Reducing maternal mortality and morbidity is a key priority of the World Health Organization (WHO).

The updated ESC Guidelines recommend that a personalized pregnancy-related risk assessment is needed in all women with cardiovascular disease. This should include reviewing their medical needs, medication and wider factors including maternal age, smoking history, comorbidities, body mass index (BMI), obstetric history and socio-economic status.

The guidelines recommend that maternal preferences should be thoroughly explored as part of the shared decision-making process.

The ESC Guidelines recommend discussions about the risks of pregnancy from puberty for young women with congenital or inherited heart disease. This is because of the high rates of unintended pregnancies, up to 45%, which have been reported in adolescents with congenital heart disease.

New guidance has also been given about medication used to treat women with cardiovascular disease during pregnancy, for example, encouraging the use of statins throughout pregnancy for some women. There are also updates to the recommended medications for high blood pressure during pregnancy, and more detailed guidance on medication in cardiogenetic disorders.

“Due to limited data on medications tolerable in pregnancy, pregnant women are at risk of receiving sub-optimal treatment. Our guidelines give detailed and up-to-date guidance to ensure that important medication is not withheld unnecessarily. We hope that health care providers and patients will find the guideline useful and that it will reach a wide clinical audience,” Professor Kristina Hermann Haugaa said.

The important role of Pregnancy Heart Teams in supporting women’s mental and physical health before, during and after pregnancy is highlighted by the updated guidance. Pregnancy Heart Teams are associated with lower maternal death rates, lower hospital readmission rates and improved patient safety.

The guidelines recommend that Institutional Pregnancy Heart Teams should be established in specialist hospitals, tailored to the geographical area, numbers of births and sociocultural factors.

“Too often, women who would benefit from care by a specialized Pregnancy Heart Team are not referred in time. Conversely, some women are referred unnecessarily, thereby putting strain on these services. This guidance clearly defines which women should receive care from a Pregnancy Heart Team,” Professor Kristina Hermann Haugaa concluded.

The updated ESC Guidelines also:

• Give clearer information about when cesarean sections are appropriate in women with cardiovascular risk. The updated guidelines note that women with cardiovascular risk often receive cesarean sections without evidence that this reduces risks, and, despite evidence that suggests, it may even increase fetal risk.
• Recommend postponing pregnancy for at least one year after heart transplantation, taking individual risk factors into account.
• Provide a more nuanced risk assessment for patient counseling responding to new data.

The ‘2025 ESC Guidelines for the management of cardiovascular disease and pregnancy” have been endorsed by the European Society of Gynecology and replace previous guidelines from 2018.

Pregnancy is a high-risk period for women with cardiovascular disease, due to the physiological changes in heart and blood system needed to meet the increased metabolic needs of the mother and fetus.

From the sixth week of pregnancy, stroke volume and cardiac output increase in women by 30–50%, and heart rate increases by 10–20 beats per minute. In women with heart disease, the adaptations needed from the heart can be faulty and can lead to heart failure and atrial and ventricular tachyarrhythmias.