ESC 2025 guidelines prioritize women’s autonomy in high-risk pregnancies

ESC 2025 guidelines prioritize women’s autonomy in high-risk pregnancies | Image Credit: © Alik Mulikov - © Alik Mulikov - stock.adobe.com.

At European Society of Cardiology (ESC) Congress 2025, updated ESC guidelines were published, prioritizing giving women autonomy in making their own reproductive decisions.¹

This is accomplished through transparent dialogue and shared decision-making, especially in high-risk pregnancies with increased odds of a maternal or fetal event. Additionally, steps have been taken to avoid suggesting pregnancy termination to women with conditions such as pulmonary arterial hypertension that make their pregnancy high-risk.

“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,” said Julie De Backer, MD, PhD, professor at Ghent University.

Importance of personalized risk assessment

An international panel of experts came together to produce the guidelines. In the guidelines, they recommend that women with cardiovascular disease undergo a personalized pregnancy-related risk assessment. During the assessment, their medical needs should be reviewed alongside relevant medications and risk factors.

Thorough explanations of maternal preferences are also recommended by the guidelines to promote a shared decision-making process. Additionally, clinicians should discuss the risks of pregnancy with young women impacted by congenital or inherited heart disease starting from puberty.

Investigators noted that this early discussion is necessary to reduce the risk of unintended pregnancy. High rates of unintended pregnancy have been reported, and up to 45% of these cases occur in adolescents with congenital heart disease.

Role of Pregnancy Heart Teams

Medication guidance during pregnancy has also been provided. This includes using statins in some women throughout pregnancy, alongside updates to medications recommended for use in patients with high blood pressure and cardiogenetic disorders.

The guidelines highlighted the vital role of Pregnancy Heart Teams in supporting the physical and mental health of women before, during, and after pregnancy. Lower maternal death and hospital readmission rates, as well as increased patient safety, have been reported in women receiving support from Pregnancy Heart Teams.

Based on this information, investigators recommended that specialist hospitals establish Pregnancy Heart Teams that are tailored to the geographic area, sociocultural factors, and number of births. According to Kristina Hermann Haugaa, MD, PhD, professor at the University of Oslo, the guidelines clarify which women should receive care from these teams, preventing underuse or overuse of these services.

Nuanced risk assessment for patient counseling

Clarity was also provided for when women with cardiovascular risk may undergo cesarean delivery. According to the guidelines, cesarean delivery is often given to women to reduce cardiovascular risk despite lacking evidence, as well as data indicating a potential increase in fetal risk from the procedure.

Based on recent data, the guidelines also included a more nuanced risk assessment for patient counselling. They recommend pregnancy be delayed by at least 1 year following heart transplantation, with individual risk factors also considered.

According to investigators, physiological changes in the heart and blood system that occur in response to increased metabolic demands during pregnancy lead to a high risk in women with cardiovascular disease. This leads to an increase in stroke volume and cardiac output between 30% and 50%, as well as a heart rate increase of 10 to 20 beats per minute.

Global burden of CVD in pregnancy

CVD presents in 4% of pregnancies worldwide, with this rate increasing to 10% when including high blood pressure disorders. This is led the World Health Organization to consider reducing maternal morbidity and mortality from CVD as a key priority.

The guidelines, presented at ESC Congress 2025 on August 29, 2025, have been endorsed by the European Society of Gynecology. They provide a significant update to the prior guidelines, which were published in 2018.

“In managing maternal and fetal health, it is essential to balance the risks and benefits of maternal and fetal therapeutic needs,” wrote investigators. “Due to the scarcity of prospective or randomized studies within this field… most recommendations in these Guidelines are based on evidence level C.”

References

1. Updated ESC Guidelines put focus on women’s autonomy to make their own reproductive choices about high-risk pregnancies. European Society of Cardiology. September 4, 2025. Accessed September 8, 2025. https://www.eurekalert.org/news-releases/1097097.
2. De Baker J, Haugaa KH, Eide Hasselberg N. 2025 ESC Guidelines for the management of cardiovascular disease and pregnancy: Developed by the task force on the management of cardiovascular disease and pregnancy of the European Society of Cardiology (ESC). European Heart Journal. 2025. doi:10.1093/eurheartj/ehaf193