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ESC 2018 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy

European Society of Cardiology｜循環器 / 妊娠｜84 ページ｜チャンク 726｜推奨 166 件｜current

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頁クラスレベル推奨文表
p.18 I C cardiovascular and aortic disease.39
p.18 I C tion, using the mWHO classification of maternal risk.11
p.18 I C It is recommended that high-risk patients are treated in specialized centres by a multidisciplinary pregnancy heart team.39
p.18 I C abnormalities.76–80
p.18 I C Echocardiography is recommended in any pregnant patient with unexplained or new cardiovascular signs or symptoms.
p.18 I C for the mother.134
p.18 I C Vaginal delivery is recommended as the first choice in most patients; for most important exceptions see below.96
p.18 IIa C Induction of labour should be considered at 40 weeks of gestation in all women with cardiac disease.
p.18 IIa C aortic disease, or genetic malformations associated with CVD.68,71
p.18 IIa C MRI (without gadolinium) should be considered if echocardiography is insufficient for a definite diagnosis.
p.18 IIa C Delivery before necessary surgery should be considered when gestational age is >_26 weeks.86–88,135
p.18 IIb C A chest radiograph may be considered if other methods are not successful in clarifying the cause of dyspnoea.
p.18 IIb C Cardiac catheterization may be considered with very strict indications.
p.18 IIb C CT and electrophysiological studies may be considered in selected patients for vital indications.
p.18 III C Prophylactic antibiotic therapy to prevent endocarditis during delivery is not recommended.112
p.18 IIb C .....................
p.22 IIa C In treatment-naive pregnant PAH patients, initiating treatment should be considered.23
p.22 III B with PAH.119
p.22 I C 4.4 Recommendations Right heart catheterization is recommended to confirm the diagnosis of PAH (group 1). This can be performed during pregnancy but with very strict indications.10
p.22 I C Treatment dose LMWH is recommended in pregnant patients with chronic thrombo- embolic pulmonary hypertension.
p.22 IIa C If a PAH patient conceives on targeted PH therapies, consideration should be given to withdrawing embryotoxic drugs, taking into account the risks of withdrawal. Pregnancy is not recommended in patients
p.22 IIa C Patients with a systemic right ventricle (Mustard/Senning or congenitally cor- rected TGA), in NYHA class III/IV, systemic ventricular dysfunction (EF <40%), or severe TR should be advised against
p.22 IIa C pregnancy. Anticoagulation treatment should be considered during pregnancy in Fontan patients.
p.22 IIa C Symptomatic patients with Ebstein’s anom- aly with saturations <85% and/or heart failure should be advised against pregnancy.
p.22 III C In patients with a Fontan circulation and sat- urations <85%, depressed ventricular func- tion, moderate–severe AV regurgitation, refractory arrhythmia, or protein-losing enteropathy, pregnancy is not recommended. 5 Aortic diseases
p.25 I C It is recommended that women with aortic disease have counselling about the risk of aortic dissection.19,178
p.25 I C Imaging of the entire aorta (CT/MRI) is recommended before pregnancy in patients with a genetically proven aortic syndrome or known aortic disease.53
p.25 I C In bicuspid aortic valve patients, imaging of the ascending aorta is recommended before pregnancy.
p.25 I C strict blood pressure control is recommended.185
p.25 I C Repeated echocardiographic imaging every 4–12 weeks (depending on diagnosis and severity of dilatation) is recommended during pregnancy and 6 months post-partum in patients with ascending aorta dilatation.194
p.25 I C gadolinium) is recommended.53
p.25 I C In patients with an ascending aorta <40 mm, vaginal delivery is recommended.96
p.25 IIa C In patients with an ascending aorta >45 mm, caesarean delivery should be considered.
p.25 IIa C In patients with (history of) aortic dissection, caesarean delivery should be considered.
p.25 IIa C Prophylactic surgery should be considered during pregnancy if the aorta diameter is >45 mm and increasing rapidly.
p.25 IIa C When the foetus is viable, delivery before necessary surgery should be considered.96
p.25 IIb C In patients with an aorta 40–45 mm, caesarean section may be considered.
p.25 III C Pregnancy is not recommended in patients with (or history of) aortic dissection.
p.25 III C When possible, the use of ergometrine is not recommended in women with aortic disease.
p.25 I C In patients with vascular Ehlers–Danlos syndrome, celiprolol is recommended.186
p.25 III C Pregnancy is not recommended in patients with severe dilatation of the aorta (heritable thoracic aortic disease such as Marfan syndrome >45 mm, bicuspid aortic valve >50 mm or >27 mm/m2 BSA, or Turner syndrome ASI >25 mm/m2 BSA).19,20
p.25 III C Pregnancy is not recommended in patients with vascular Ehlers–Danlos syndrome.26
p.31 I B In patients with symptoms or pulmonary hypertension, restricted activities and beta-1-selective blockers are recommended.5,204
p.31 I B Diuretics are recommended when congestive symptoms persist despite beta-blockers.5
p.31 I C Intervention is recommended before pregnancy in patients with MS and valve area <1.0 cm2.
p.31 IIa C Intervention should be considered before pregnancy in patients with MS and valve area <1.5 cm2.
p.31 I B  they are symptomatic
p.31 I C  OR LV dysfunction (LVEF <50%) is present204
p.31 I C  OR when they develop symptoms during exercise testing.
p.31 IIa C Balloon aortic valvuloplasty should be considered during pregnancy in patients with severe aortic stenosis and severe symptoms.
p.31 I C impaired ventricular function or ventricular dilatation.204
p.31 I C Medical therapy is recommended in pregnant women with regurgitant lesions when symptoms occur.
p.31 I C 6.6 Recommendations
p.32 I C It is recommended to manage pregnancy in women with mechanical valves in a centre with a pregnancy heart team.
p.32 I C If delivery starts while on a VKA or in less than 2 weeks after discontinuation of a VKA, caesarean section is recommended.
p.32 I C In pregnant women on a VKA, it is recommended to perform INR monitoring weekly or every 2 weeks.
p.32 I C It is recommended to anticipate the timing of delivery to ensure safe and effective peripartum anticoagulation.
p.32 I C It is recommended to implement changes in the anticoagulation regimen during pregnancy in hospital.
p.32 I C During the second and third trimesters until the 36th week, VKAs are recommended in women needing a low dose.d
p.32 IIa C A bioprostheses should be considered in young women contemplating pregnancy.
p.32 IIa C During the second and third trimesters until the 36th week, VKAs should be considered in women needing a high dose.e
p.32 III C LMWH is not recommended when weekly anti-Xa level monitoring and dose-adjustment is not available.
p.34 I C 7.8 Recommendations ECG and measurement of troponin levels are recommended when a pregnant woman has chest pain.225,227
p.34 I C Primary coronary angioplasty is recom- mended as the preferred reperfusion ther- apy for STEMI during pregnancy.226
p.34 IIa C An invasive management strategy should be considered for NSTE-ACS with high risk criteria.226
p.34 IIa C Conservative management should be considered for stable NSTE-ACS with low risk criteria.
p.34 IIa C Follow-up should be considered over at least the next 3 months.
p.34 III C Breastfeeding is not recommended in moth- ers who take antiplatelet agents other than low-dose aspirin due to a lack of data (see section 12).
p.38 I A embolism.286
p.38 I C peripartum.29
p.38 IIa C As rapid diagnosis and decision-making is crucial for all pregnant women with acute HF, a pre-specified management algorithm and an interdisciplinary team should be established.279,290
p.38 IIa C Bromocriptine treatment should be accompanied by prophylactic (or therapeutic) anticoagulation.
p.38 IIb B Due to the high metabolic demands of lactation and breastfeeding, preventing lactation may be considered in patients with severe HF.24
p.38 IIb B In patients with PPCM, bromocriptine treatment may be considered to stop lactation and enhance recovery (LV function).
p.38 III C In women with PPCM and DCM, subsequent pregnancy is not recommended if LVEF does not normalize.285
p.38 I C In patients with HCM, the same risk stratifications as for non-pregnant women are recommended.313
p.38 I C In patients with HCM, it is recommended that beta-blockers are continued in women who used them before pregnancy.313
p.38 IIa C In HCM, cardioversion should be considered for persistent atrial fibrillation.306
p.38 I B 8.5 Recommendations
p.41 I C Low-risk PSVT, AF, idiopathic VT, low-risk LQTS, WPW syndrome 1
p.42 I C Vagal manoeuvres and if these fails, adenosine are recommended for acute conversion of PSVT.12,326,327
p.42 I C AF.12,306,326,336–338
p.42 IIa C Beta-1-selective blockers should be considered for acute conversion of PSVT.12,326
p.42 IIb C Ibutilide or flecainide may be considered for termination of atrial flutter and AF in stable patients with structurally normal hearts.c 12,329
p.42 I C ing ECG.12,327
p.42 I C Flecainidee or propafenonee are recommended for the prevention of SVT in patients with WPW syndrome.12
p.42 I C Beta-selective blockers are recommended for rate control of AT or AF.12
p.42 IIa C Flecainidee, propafenone,e or sotalolf should be considered to prevent SVT, AT, and AF if AV nodal blocking agents fail.12
p.42 IIa C Digoxind and verapamild should be considered for rate control of AT or AF if beta-blockers fail.
p.42 IIa C poorly tolerated SVT.15–17
p.42 I C Immediate electrical cardioversion is recommended for sustained both unstable and stable VT.72,326,336–338
p.42 IIa C For acute conversion of sustained, haemodynamically stable, monomorphic VT (e.g. idiopathic VT), a beta-blocker, sotalol,f flecainide,e procainamide, or overdrive ventricular pacing should be considered.72
p.42 I C nergic polymorphic VT.72,323
p.42 I C symptoms or haemodynamic compromise.72,331
p.42 IIa C In idiopathic sustained VT, sotalolf or flecainidee should be considered for prevention if other drugs fail.72
p.42 IIb C tory and poorly tolerated VT if there are no other alternatives.15–17
p.45 I A Low-dose aspirin (100–150 mg daily) is recommended in women at high or moderate risk of pre-eclampsia from week 12 to weeks 36–37.343,344
p.45 I B In women with gestational hypertension or mild pre-eclampsia, delivery is recommended at 37 weeks.383
p.45 I C recommended.361
p.45 I C recommended.51
p.45 IIa C Limitation of weight gain to <6.8 kg should be considered in obese women.377
p.45 III C ACE inhibitors, ARBs, or direct renin inhibitors are not recommended.51,185,361
p.48 I B LMWH is recommended for the prevention and treatment of VTE in pregnant patients.13
p.48 I B For high-risk women, it is recommended to give a weight-related prophylactic dose of LMWH (e.g. enoxaparin 0.5 mg/kg once daily).13
p.48 I C A documented assessment of risk factors for VTE before pregnancy or in early pregnancy is recommended in all women.417
p.48 I C It is recommended that the therapeutic dose of LMWH is based on body weight.14
p.48 I C Thrombolytics to manage patients with pulmonary embolism is only recommended in patients with severe hypotension or shock.21
p.48 I C In high-risk women, it is recommended to convert LMWH to UFH at least 36 h prior to delivery and stop the UFH infusion 4–6 h prior to anticipated delivery. aPTT should be normal before regional anaesthesia.22
p.48 I C dose of LMWH.22
p.48 I C trimester.418
p.48 IIa C In women who are on antenatal anticoagulation, it should be considered to actively manage the third stage of labour with oxytocin.105
p.48 IIa C sis before using computed tomography pulmonary angiography or ventilation perfusion scanning.18
p.48 IIa C In women on therapeutic LMWH, planned delivery should be considered at around 39 weeks to avoid the risk of spontaneous labour while fully anticoagulated (LMWH is only partially reversed with protamine).419
p.48 III C Direct oral anticoagulants are not recommended in pregnancy.420
p.50 III C egories alone is no longer recommended.11
p.50 I C 12.5 Recommendations Before pharmacological treatment in pregnancy is started, it is recommended to check Table 7 for clinical safety data.
p.50 I C In the absence of clinical safety data, it is recommended to check the electronic drug table (www.safefetus.com) for pre-clinical safety data.
p.50 IIa C In the absence of adequate human safety data, decision-making should be based on individual drug efficacy and safety profiles, and the available animal data, and the decision must be made together with the patient. Decision-making based on former FDA cat- FDA = US Food and Drug Administration. aClass of recommendation. bLevel of evidence.
p.69 I C ovascular and aortic disease.39
p.69 I C It is recommended to treat high risk patients in specialized centres by a multidisciplinary team: the pregnancy heart team.39
p.69 I C Echocardiography is recommended in any pregnant patient with unexplained or new cardiovascular signs or symptoms
p.69 I C Vaginal delivery is recommended as first choice in most patients; for most important exceptions see below.96
p.69 III C Prophylactic antibiotic therapy to prevent endocarditis during delivery is not recommended.112
p.69 I C nancy but with very strict indications, optimal timing, and shielding of the foetus.10
p.69 III B Pregnancy is not recommended in patients with PAH.119
p.69 III C Pregnancy is not recommended in patients after Fontan operation and any associated complication.
p.69 I C or known aortic disease.53
p.69 I C When a woman with known aortic dilatation, (history of) dissection, or genetic predisposition for dissection becomes pregnant, strict blood pressure control is recommended.185
p.69 I C during pregnancy and 6 months post-partum in patients with ascending aorta dilatation.194
p.69 I C In patients with an ascending aorta <40 mm, vaginal delivery is recommended.96
p.69 III C Pregnancy is not recommended in patients with vascular Ehlers–Danlos syndrome.26
p.69 I B recommended.5,204
p.69 I B Diuretics are recommended when congestive symptoms persist despite beta-blockers.5
p.70 I C Intervention is recommended before pregnancy in patients with MS and valve area <1.0 cm2.
p.70 I C Therapeutic anticoagulation using heparins or VKA is recommended in case of AF, left atrial thrombosis, or prior embolism.
p.70 I B Intervention is recommended before pregnancy in patients with severe AS if they are symptomatic.
p.70 I C impaired ventricular function, or ventricular dilatation.204
p.70 I C Medical therapy is recommended in pregnant women with regurgitant lesions when symptoms occur.
p.70 I C It is recommended to manage pregnancy in women with mechanical valves in a centre with a pregnancy heart team.
p.70 I C If delivery starts while on VKA or in less than 2 weeks after discontinuation of a VKA, caesarean section is indicated.
p.70 I C It is recommended to anticipate the timing of delivery to ensure safe and effective peripartum anticoagulation.
p.70 I C Immediate echocardiography is indicated in women with mechanical valves presenting with dyspnoea and/or an embolic event.
p.70 I C During the second and third trimesters until the 36th week, VKAs are recommended in women needing a low dose.a
p.70 I C ECG and measurement of troponin levels is recommended when a pregnant woman has chest pain.238
p.70 I C Primary coronary angioplasty is recommended as the preferred reperfusion therapy for STEMI during pregnancy.237
p.70 I A Anticoagulation is recommended in patients with intracardiac thrombus detected by imaging or with evidence of systemic embolism.286
p.70 I C peripartum.29
p.70 I C Therapeutic anticoagulation with LMWH or VKAs according to stage of pregnancy is recommended for patients with AF.
p.70 I C even after recovery of LV function.
p.71 I C In patients with HCM, it is recommended that beta-blockers are continued in women who used them before pregnancy.313
p.71 I C Immediate electrical cardioversion is recommended for any tachycardia with haemodynamic instability and for pre-excited AF.12,306
p.71 I C resting ECG.12,327
p.71 I C Flecainidec or propafenonec are recommended for the prevention of SVT in patients with WPW syndrome.12
p.71 I C Beta-1-selective blockers are recommended for rate control of AT or AF.12
p.71 I C Immediate electrical cardioversion is recommended for both sustained unstable and stable VT.72
p.71 I C nergic polymorphic ventricular tachycardia.72
p.71 I A Low-dose aspirin (100–150 mg daily) is recommended in women at high or moderate risk of pre-eclampsia from week 12 to week 36 - 37.347,348
p.71 I C SBP >_170 mmHg or DBP >_110 mmHg in a pregnant woman is an emergency, and hospitalization is recommended.
p.71 I C Methyldopa, labetalol, and calcium antagonists are the drugs of choice for the treatment of hypertension in pregnancy.51,379,389
p.71 I C In severe hypertension, drug treatment with intravenous labetalol, oral methyldopa, or nifedipine is recommended.51
p.71 I B LMWH is recommended for the prevention and treatment of VTE in pregnant patients.13
p.71 I B For high-risk women, it is recommended to give a weight-related prophylactic dose of LMWH (e.g. enoxaparin 0.5 mg/kg once daily).13
p.71 I C It is recommended that the therapeutic dose of LMWH is based on body weight.14
p.71 I C In high-risk women, it is recommended to convert LMWH to UFH at least 36 h prior to delivery and to stop the UFH infusion 4 - 6 h prior to anticipated delivery. aPTT should be normal before regional anaesthesia.22
p.72 I C Before pharmacological treatment in pregnancy is started, it is recommended to check drugs and safety data (see Table 7)
p.72 III C Decision making based on former FDA categories alone is no longer recommended.