How to manage a 19-year-old primigravida at 33+1 weeks gestation with heart failure with reduced ejection fraction (HFrEF), pulmonary congestion, and uncontrolled hypertension despite being on injection furosemide (Lasix) 60mg IV three times a day and isosorbide dinitrate (Isoket)?

Management of Peripartum Cardiomyopathy with Hypertension in a 19-Year-Old Primigravida

The patient requires urgent delivery by cesarean section under epidural anesthesia, followed by implementation of standard heart failure therapy including ACE inhibitors, beta-blockers, diuretics, and anticoagulation. 1

Immediate Management

Blood Pressure Control

• Continue IV isosorbide dinitrate (Isoket) but add IV hydralazine for better blood pressure control
• Target systolic BP <140 mmHg (rather than <160 mmHg) to reduce cardiac stress while maintaining placental perfusion
• Avoid ACE inhibitors/ARBs until after delivery due to fetotoxicity 1

Pulmonary Congestion Management

• Continue IV furosemide 60mg TID to manage pulmonary edema
• Monitor oxygen saturation closely, maintain >94%
• Position patient in semi-upright position to improve respiratory mechanics

Delivery Planning

Timing and Method

• Arrange urgent delivery regardless of gestation due to maternal hemodynamic instability 1
• Cesarean section under epidural anesthesia is preferred to minimize hemodynamic fluctuations
• Coordinate with obstetrics, anesthesia, and neonatal teams for delivery planning

Perioperative Management

• Continuous hemodynamic monitoring during delivery
• Have vasopressors and inotropes available for hemodynamic support if needed
• Consider arterial line placement for beat-to-beat BP monitoring

Post-Delivery Management

Immediate Post-Delivery Care

• Implement standard heart failure therapy once hemodynamically stable after delivery 1
• Start anticoagulation with LMWH due to high risk of thromboembolism with LVEF <35% 1, 2
• Monitor for postpartum hemorrhage, which may be exacerbated by anticoagulation

Heart Failure Medications

• Begin ACE inhibitor (enalapril 2.5mg BID, titrate to 10-20mg BID) 1, 2
• Start beta-blocker (metoprolol succinate 12.5-25mg daily) 1, 2
• Add mineralocorticoid receptor antagonist (spironolactone 25mg daily) if renal function permits 1, 2
• Continue diuretic therapy as needed for congestion
• Consider hydralazine and nitrates for additional afterload reduction 1, 3

Advanced Therapies

• Consider bromocriptine addition to standard therapy to improve LVEF recovery 1
• If using bromocriptine, ensure therapeutic anticoagulation due to increased thrombotic risk
• Evaluate for mechanical circulatory support if patient deteriorates despite medical therapy

Monitoring and Follow-up

• Repeat echocardiography at 3 months to assess LVEF recovery 2
• Monitor renal function and electrolytes closely with medication adjustments
• Regular follow-up every 2-4 weeks during medication uptitration 2
• Contraception counseling is essential as future pregnancies carry 30-50% risk of recurrence 1

Potential Pitfalls and Caveats

• Avoid excessive diuresis which may compromise placental perfusion prior to delivery
• Do not withhold anticoagulation due to fear of bleeding unless active hemorrhage is present
• Remember that hydralazine and nitrates are safe alternatives to ACE inhibitors during pregnancy
• Recognize that some medications (ACE inhibitors, beta-blockers) can be used during breastfeeding with careful monitoring of the infant 1
• Be aware that excessive concern about hypotension should not prevent appropriate uptitration of life-saving medications post-delivery 4

This patient presents with classic peripartum cardiomyopathy with reduced ejection fraction complicated by hypertension. The immediate priority is stabilizing her condition and proceeding with delivery, after which standard heart failure therapy can be fully implemented to improve outcomes.