Is pregnancy contraindicated in a woman with dilated cardiomyopathy and severely reduced left ventricular (LV) function, specifically an ejection fraction (EF) of 35%?

From the Guidelines

Pregnancy is generally contraindicated in women with dilated cardiomyopathy and severely reduced left ventricular function with an ejection fraction of 35%. Women with this condition should be strongly advised against pregnancy due to the significant maternal and fetal risks involved, as supported by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. The hemodynamic changes of pregnancy, including increased blood volume and cardiac output, place additional strain on an already compromised heart, potentially leading to heart failure decompensation, arrhythmias, or even maternal death.

Before conception, these women should undergo comprehensive cardiac evaluation and optimization of heart failure medications that are pregnancy-compatible, such as beta-blockers (metoprolol, carvedilol) and hydralazine with nitrates. ACE inhibitors, ARBs, and ARNI medications must be discontinued before conception due to their teratogenic effects, as recommended by the ESC guidelines on the management of cardiovascular diseases during pregnancy 1. If a woman with this condition becomes pregnant, she requires multidisciplinary care involving maternal-fetal medicine specialists and cardiologists with expertise in pregnancy.

Close monitoring with frequent echocardiograms, careful fluid management, and hospitalization during the third trimester and peripartum period may be necessary. The peripartum period is particularly high-risk as rapid fluid shifts can precipitate heart failure. Delivery planning should include consideration for assisted second stage of labor and careful anesthesia management to minimize cardiac stress. Anticoagulation therapy should also be considered in patients with severely depressed LVEF, especially in the first 6 to 8 weeks postpartum, as suggested by the 2022 AHA/ACC/HFSA guideline 1.

Key considerations for managing these patients include:

• Comprehensive cardiac evaluation and optimization of heart failure medications before conception
• Discontinuation of ACE inhibitors, ARBs, and ARNI medications before conception
• Multidisciplinary care involving maternal-fetal medicine specialists and cardiologists with expertise in pregnancy
• Close monitoring with frequent echocardiograms and careful fluid management
• Hospitalization during the third trimester and peripartum period
• Consideration for assisted second stage of labor and careful anesthesia management
• Anticoagulation therapy in patients with severely depressed LVEF, as recommended by the 2022 AHA/ACC/HFSA guideline 1 and the ESC guidelines on the management of cardiovascular diseases during pregnancy 1.

The most recent and highest quality study, the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, provides the strongest evidence for the management of women with dilated cardiomyopathy and severely reduced left ventricular function during pregnancy.

From the Research

Pregnancy Considerations in Women with Dilated Cardiomyopathy

• Women with dilated cardiomyopathy and severely reduced left ventricular (LV) function, specifically an ejection fraction (EF) of 35%, are at increased risk of maternal and fetal mortality and morbidity 2.
• These women should undergo preconception evaluation, risk assessment, and treatment modification, including discontinuation and replacement of contraindicated medications 2.
• A close follow-up and treatment by a multidisciplinary team is recommended at all stages: preconception, gestation, delivery, and postpartum 2.

Risk Assessment and Predictors of Adverse Outcome

• Predictors of deterioration during pregnancy that are considered very high risk and should be advised to avoid pregnancy are: patients with NYHA FC III/IV unless improved under treatment and LVEF < 20% 2.
• Predictors for high risk of adverse outcome include: LVEF < 30%, NYHA FC II, ventricular tachyarrhythmias, atrial fibrillation with rapid ventricular rate, severe mitral regurgitation, significant right ventricular failure, and hypotension 2.
• In this case, a woman with an EF of 35% would be considered at high risk of adverse outcome, but not necessarily advised to avoid pregnancy altogether 2.

Management and Delivery Recommendations

• The recommended mode of delivery for most patients is vaginal, with cesarian section indications being mainly obstetric, unless the patient is in severely decompensated heart failure or urgent delivery if the patient is receiving warfarin therapy 2.
• An early gestational and delivery plan should be prepared to face complications and to achieve a successful delivery and outcome 2.
• Long-term postpartum cardiac follow-up is recommended, anticipating potential adverse effects of pregnancy 2.