Safe Cardiac Medications for Pregnant Women
Beta-blockers (specifically metoprolol and propranolol) and digoxin are the safest cardiac medications for pregnant women requiring treatment for cardiovascular conditions.
Antiarrhythmic Medications
First-line Medications
- For supraventricular tachycardia (SVT) management, oral digoxin or metoprolol/propranolol are recommended as first-line agents during pregnancy 1
- For long-term management of idiopathic sustained ventricular tachycardia (VT), oral metoprolol, propranolol, or verapamil are recommended 1
- For acute conversion of paroxysmal SVT, vagal maneuvers followed by intravenous adenosine is the recommended approach 1
Second-line Medications
- If digoxin or beta-blockers fail for SVT management, oral sotalol or flecainide should be considered 1
- For focal atrial tachycardia, flecainide, propafenone, or sotalol can be used for patients with significant symptoms 1
- Intravenous metoprolol or propranolol should be considered for acute conversion of paroxysmal SVT if adenosine fails 1
Medications to Avoid
- Atenolol should not be used for any arrhythmia during pregnancy 1, 2
- Amiodarone should only be used when all other therapy has failed and at the lowest effective dose due to fetotoxic effects 1
Beta-Blockers in Pregnancy
Safe Beta-Blockers
- Metoprolol is preferred for pregnant women requiring beta-blockade 1, 3
- Propranolol can be safely used during pregnancy but should be used with caution in the first trimester 1, 4
- Beta-blockers are particularly recommended for women with hypertrophic cardiomyopathy (HCM) with left ventricular outflow tract obstruction 1
Concerns with Beta-Blockers
- Neonates whose mothers receive beta-blockers at parturition should be monitored for 24-48 hours after delivery to exclude hypoglycemia, bradycardia, and respiratory depression 1, 4
- Beta-blockers may be associated with intrauterine growth restriction, though this risk varies between agents 3
Heart Failure Medications
Safe Medications
- Hydralazine and nitrates can be used for afterload reduction instead of ACE inhibitors/ARBs during pregnancy 1
- Furosemide and hydrochlorothiazide can be used if pulmonary congestion is present, though diuretics should be used cautiously as they may decrease placental blood flow 1
- Dopamine and levosimendan can be used if inotropic drugs are needed 1
Medications to Avoid
- ACE inhibitors, ARBs, and renin inhibitors are contraindicated during pregnancy due to fetotoxicity 1, 5
- Aldosterone antagonists (spironolactone) should be avoided, especially in the first trimester due to potential antiandrogenic effects 1
Anticoagulation in Pregnancy
- Therapeutic anticoagulation with low molecular weight heparin (LMWH) or vitamin K antagonists (according to stage of pregnancy) is recommended for patients with atrial fibrillation 1
- Anticoagulation is recommended in patients with intracardiac thrombus detected by imaging or with evidence of systemic embolism 1
- When LMWH is used, anti-Xa levels should be monitored 1
Special Considerations
Breastfeeding
- Some ACE inhibitors (benazepril, captopril, enalapril) have been sufficiently tested in breastfeeding women and can be safely used postpartum 1
- Children's weight monitoring during the first 4 weeks of breastfeeding while mother is on ACE inhibitors is essential to monitor for kidney dysfunction 1
Hypertension Management
- Methyldopa, labetalol, and nifedipine appear safe for use in pregnancy for hypertension management 6, 7
- Nifedipine may be more effective than methyldopa for blood pressure control in severe hypertension during pregnancy 7
Procedural Interventions
- Immediate electrical cardioversion is recommended for any tachycardia with hemodynamic instability 1
- Implantation of permanent pacemakers or ICDs (preferably one chamber) should be considered with echocardiographic guidance, especially if the fetus is beyond 8 weeks gestation 1
- Catheter ablation may be considered in cases of drug-refractory and poorly tolerated tachycardias, but should be reserved for special cases during pregnancy 1