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cardio.cardio-obstetric.preconception.v1PRODUCTION
cardio.cardio-obstetric.preconception.v1

Cardio-obstetric: pre-pregnancy risk + pregnancy cardiac management (cross-system)

cardiologychronicadultpregnancy
Hard-required inputs
0 / 7
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Determine phase (pre-conception/pregnant/post-partum) + lesion → assign mWHO class

Inputs
2
Actions
0
Advance rule
Set
Advance when

phase + lesion + provisional mWHO framed

Patient inputs (10)

Identify teratogenic cardiac drugs to substitute

Contemplating vs pregnant (trimester) vs post-partum — phase-specific management

Lesion type drives mWHO class + lesion-specific management

Systemic-ventricular EF <30 / NYHA III–IV = mWHO IV

Severe MS/AS, Marfan aorta >45 mm / bicuspid >50 mm, severe coarctation = mWHO IV

Functional class — CARPREG II + mWHO input

Pregnancy-compatible drug dosing; cardiorenal

Mechanical valve = warfarin-vs-LMWH anticoagulation dilemma

Baseline + serial NP for HF/PPCM surveillance in pregnancy

Severe PAH/Eisenmenger = mWHO IV (highest maternal mortality)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningmwho_iv_pregnancy_contraindicated
    mWHO IV (severe PAH/Eisenmenger, systemic-ventricular EF<30/NYHA III–IV, severe MS, severe symptomatic AS, Marfan aorta >45 mm / bicuspid >50 mm, native severe coarctation, prior PPCM with residual dysfunction) — pregnancy CONTRAINDICATED: effective contraception; if pregnant, expert counseling incl. termination — 2018 ESC Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmechanical_valve_ac_branch
    Mechanical valve in pregnancy — warfarin (most thromboprotective, teratogenic 1st trimester) vs LMWH (safer fetus, valve-thrombosis risk) shared decision; switch near delivery — 2018 ESC Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningperipartum_cardiomyopathy_branch
    Peripartum cardiomyopathy (current or prior with residual dysfunction) — bromocriptine + anticoagulation + GDMT (postpartum); prior PPCM = high recurrence/mWHO escalation — BOARD; 2018 ESC Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereteratogen_substitution_branch
    On ACEi/ARB/ARNi/SGLT2i/finerenone/spironolactone/statin (or amiodarone) + pregnancy/planning — substitute pregnancy-compatible regimen immediately — 2018 ESC Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaortopathy_branch
    Marfan/Loeys-Dietz/bicuspid/Turner aortopathy — dissection risk peaks peripartum; aortic imaging each trimester; pre-pregnancy surgery at lower threshold; BB throughout — 2018 ESC Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_valve_pre_pregnancy_branch
    Severe MS / severe symptomatic AS — pre-pregnancy balloon valvotomy / intervention to reduce maternal risk — 2018 ESC Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereachd_pregnancy_branch
    ACHD in pregnancy (TOF/Fontan/transposition/shunts) — lesion-specific mWHO + expert ACHD-obstetric care; Fontan/Eisenmenger very high risk — 2018 ESC Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepostpartum_decompensation_window
    Early post-partum (auto-transfusion + fluid shifts) — highest decompensation window for valve/HF/PPCM/PH — intensified monitoring, planned admission for high-risk — 2018 ESC Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatearrhythmia_pregnancy_branch
    Arrhythmia in pregnancy — pregnancy-compatible AAD (BB, digoxin; flecainide/sotalol selected; AVOID amiodarone); cardioversion safe if needed — 2018 ESC Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Cardio-obstetric — mWHO risk + teratogen substitution + lesion/delivery planning (2018 ESC Pregnancy; CARPREG II)
axis: cardio_obstetric_risk_and_teratogen_substitutionstep 1 - Step 1 — mWHO + CARPREG II risk stratification + counseling stance
Selected step "Step 1 — mWHO + CARPREG II risk stratification + counseling stance" — Any woman with cardiac disease contemplating/in pregnancy
  • mWHO + CARPREG II/ZAHARA risk stratification + pre-conception counseling (incl. contraception/termination counseling if mWHO IV)
    first line
    risk_counseling
    triggers: cardiac_disease_pregnancy_or_planning
    2018 ESC Pregnancy — mWHO drives care level; mWHO IV = pregnancy contraindicated → effective contraception + (if pregnant) termination discussion

outpatient playbook — drug actions (3)

  1. 1. substitute teratogens → pregnancy-compatible regimen
    labetalol/metoprolol/hydralazine/nifedipine/methyldopa/digoxin • PO • per drug
    trigger: On teratogenic cardiac drug + pregnancy/planning (2018 ESC Pregnancy)
    Eliminate fetal harm while maintaining cardiac control
  2. 2. mechanical-valve AC plan (warfarin vs LMWH)
    shared decision • PO/SC • per strategy
    trigger: Mechanical valve (2018 ESC Pregnancy)
    Balance maternal valve thrombosis vs fetal warfarin embryopathy
  3. 3. bromocriptine + GDMT for peripartum CM
    per PPCM protocol • PO • per protocol
    trigger: PPCM (postpartum) (BOARD)
    Bromocriptine + anticoagulation + postpartum GDMT

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Pre-conception counseling — known cardiac disease; Pregnancy with known/new cardiac disease; New cardiac symptoms during pregnancy/post-partum.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardio-obstetric: pre-pregnancy risk + pregnancy cardiac management (cross-system)** (cardio.cardio-obstetric.preconception.v1).
Phenotype framing: mWHO class assignment (I–IV); lesion-specific maternal/fetal risk profile
Scope: Determine phase (pre-conception/pregnant/post-partum) + lesion → assign mWHO class

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cardio-obstetric — mWHO risk + teratogen substitution + lesion/delivery planning (2018 ESC Pregnancy; CARPREG II)** — step "Step 1 — mWHO + CARPREG II risk stratification + counseling stance".
1. mWHO + CARPREG II/ZAHARA risk stratification + pre-conception counseling (incl. contraception/termination counseling if mWHO IV) (risk_counseling, first line) — 2018 ESC Pregnancy — mWHO drives care level; mWHO IV = pregnancy contraindicated → effective contraception + (if pregnant) termination discussion

Setting playbook (outpatient) — mWHO/CARPREG risk-stratify, substitute teratogens, lesion-specific + delivery planning, counsel contraindicated pregnancy (2018 ESC Pregnancy)
2. substitute teratogens → pregnancy-compatible regimen labetalol/metoprolol/hydralazine/nifedipine/methyldopa/digoxin PO per drug — On teratogenic cardiac drug + pregnancy/planning (2018 ESC Pregnancy) (Eliminate fetal harm while maintaining cardiac control)
3. mechanical-valve AC plan (warfarin vs LMWH) shared decision PO/SC per strategy — Mechanical valve (2018 ESC Pregnancy) (Balance maternal valve thrombosis vs fetal warfarin embryopathy)
4. bromocriptine + GDMT for peripartum CM per PPCM protocol PO per protocol — PPCM (postpartum) (BOARD) (Bromocriptine + anticoagulation + postpartum GDMT)

Non-pharmacologic actions:
- Pregnancy-heart-team / expert maternal-cardiac centre referral by mWHO — 2018 ESC Pregnancy
- Contraception + (if mWHO IV) termination counseling — 2018 ESC Pregnancy
- Pre-pregnancy valve/aortic intervention where indicated — 2018 ESC Pregnancy
- Delivery-mode + anesthesia + post-partum-monitoring plan — 2018 ESC Pregnancy

AVOID / contraindication checks:
- MWHO IV pregnancy contraindicated effective contraception and termination counseling — 2018 ESC Pregnancy
- STOP ACEi ARB ARNi SGLT2i finerenone spironolactone statin in pregnancy — fetotoxic
- Avoid amiodarone in pregnancy fetal thyroid neuro — 2018 ESC Pregnancy
- Mechanical valve AC shared decision warfarin vs LMWH switch near delivery — 2018 ESC Pregnancy
- Treat severe valve or aortopathy pre pregnancy — 2018 ESC Pregnancy
- Post partum is the highest risk decompensation window — 2018 ESC Pregnancy

Monitoring

Regimen monitoring:
- mWHO determined surveillance cadence each trimester — 2018 ESC Pregnancy
- echo and natriuretic peptide for HF PPCM — 2018 ESC Pregnancy
- anti Xa if LMWH INR if warfarin — 2018 ESC Pregnancy
- intensified peripartum and early postpartum monitoring — 2018 ESC Pregnancy
- aortic imaging in aortopathy each trimester — 2018 ESC Pregnancy

Setting (outpatient) monitoring:
- Trimester + peripartum surveillance by mWHO; aortic imaging in aortopathy — 2018 ESC Pregnancy

Follow-up plan: Post-partum decompensation window (esp. PPCM/valve/PH); future-pregnancy + contraception counseling
- Close-out criterion: post-partum + future-pregnancy plan documented

Monitoring phase: Trimester + peripartum surveillance (echo/NP/symptom); intensified by mWHO class

Disposition

Current setting: outpatient — mWHO/CARPREG risk-stratify, substitute teratogens, lesion-specific + delivery planning, counsel contraindicated pregnancy (2018 ESC Pregnancy)

Disposition criteria:
- mWHO I–II → local obstetric + cardiology shared care
- mWHO III → expert pregnancy-heart-team centre
- mWHO IV → counsel against pregnancy / expert centre if ongoing

Escalation triggers (move to higher acuity):
- mWHO IV pregnant → urgent expert counseling (termination discussion) — 2018 ESC Pregnancy
- Decompensation / PPCM / dissection → ED + acute pathway — 2018 ESC Pregnancy
- Post-partum decompensation → intensified monitoring/admission — 2018 ESC Pregnancy

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] mWHO IV (severe PAH/Eisenmenger, systemic-ventricular EF<30/NYHA III–IV, severe MS, severe symptomatic AS, Marfan aorta >45 mm / bicuspid >50 mm, native severe coarctation, prior PPCM with residual dysfunction) — pregnancy CONTRAINDICATED: effective contraception; if pregnant, expert counseling incl. termination — 2018 ESC Pregnancy
- [LIFE_THREATENING] Mechanical valve in pregnancy — warfarin (most thromboprotective, teratogenic 1st trimester) vs LMWH (safer fetus, valve-thrombosis risk) shared decision; switch near delivery — 2018 ESC Pregnancy
- [LIFE_THREATENING] Peripartum cardiomyopathy (current or prior with residual dysfunction) — bromocriptine + anticoagulation + GDMT (postpartum); prior PPCM = high recurrence/mWHO escalation — BOARD; 2018 ESC Pregnancy

Citations

- 2018 ESC Pregnancy Guideline (Regitz-Zagrosek) + CARPREG II (Silversides); BOARD (bromocriptine PPCM) [PMID:30165544](https://pubmed.ncbi.nlm.nih.gov/30165544/)
- Cited evidence (PMID 29447873) [PMID:29447873](https://pubmed.ncbi.nlm.nih.gov/29447873/)
- Cited evidence (PMID 35379504) [PMID:35379504](https://pubmed.ncbi.nlm.nih.gov/35379504/)
- Cited evidence (PMID 37622666) [PMID:37622666](https://pubmed.ncbi.nlm.nih.gov/37622666/)

Last reconciled with current guidelines: 2026-05-16.
References
  • 2018 ESC Pregnancy Guideline (Regitz-Zagrosek) + CARPREG II (Silversides); BOARD (bromocriptine PPCM) — PMID:30165544
  • Cited evidence (PMID 29447873) — PMID:29447873
  • Cited evidence (PMID 35379504) — PMID:35379504
  • Cited evidence (PMID 37622666) — PMID:37622666