What medications are recommended for pregnant women with cardiac conditions?

Recommended Cardiac Medications for Pregnant Women

For pregnant women with cardiac conditions, first-line medications include beta-blockers (metoprolol, propranolol), calcium channel blockers (nifedipine), digoxin, and labetalol, while ACE inhibitors, ARBs, and direct renin inhibitors are strictly contraindicated due to fetotoxicity. 1, 2

Antiarrhythmic Medications

Supraventricular Tachycardias (SVT)

• For acute conversion of paroxysmal SVT:

  • First: Vagal maneuvers should be attempted 2
  • Second: IV adenosine is the first-line pharmacological treatment 2
  • Third: IV metoprolol or propranolol should be considered if adenosine fails 1

• For long-term management of SVT:

  • First-line: Oral digoxin or metoprolol/propranolol 1, 2
  • Second-line: Oral sotalol or flecainide if first-line agents fail 1
  • Third-line: Oral propafenone or procainamide may be considered if other agents fail 1

Ventricular Tachycardias (VT)

• Immediate electrical cardioversion is recommended for sustained, unstable, and stable VT 1
• For long-term management of idiopathic sustained VT:
  • First-line: Oral metoprolol, propranolol, or verapamil 1, 2
  • Second-line: Oral sotalol, flecainide, or propafenone if first-line drugs fail 1
• For congenital long QT syndrome, beta-blockers are recommended during pregnancy and postpartum 1

Hypertension Management in Pregnancy

First-Line Antihypertensive Medications

• Dihydropyridine calcium channel blockers (preferably extended-release nifedipine) 1, 3
• Labetalol 1, 3
• Methyldopa 1

Treatment Thresholds and Targets

• Start drug treatment when confirmed office BP ≥140/90 mmHg 1
• Target BP below 140/90 mmHg but not below 80 mmHg for diastolic BP 1
• SBP ≥170 mmHg or DBP ≥110 mmHg is considered an emergency requiring hospitalization 1

Important Considerations

• Beta-blockers should be used with caution in the first trimester 1
• Atenolol should not be used during pregnancy due to risk of fetal growth restriction 1, 4
• High-dose beta-blockers are associated with a five-fold increased risk of small-for-gestational-age infants 4
• For hypertensive crisis, IV labetalol, hydralazine, or immediate-release oral nifedipine should be administered within 30-60 minutes 5

Heart Failure Management

• For afterload reduction, hydralazine and nitrates are recommended instead of ACE inhibitors/ARBs 2
• Diuretics (furosemide, hydrochlorothiazide) can be used cautiously if pulmonary congestion is present 2
• For inotropic support, dopamine and levosimendan can be used 2
• Beta-blockers should be continued in women who were on them before pregnancy 2

Contraindicated Medications

• ACE inhibitors, ARBs, and direct renin inhibitors are strictly contraindicated throughout pregnancy due to severe fetotoxicity 1, 2
• Aldosterone antagonists (spironolactone) should be avoided, especially in the first trimester 2
• Atenolol should not be used for any arrhythmia during pregnancy 1

Anticoagulation in Pregnancy

• Therapeutic anticoagulation with low molecular weight heparin (LMWH) is recommended for patients with atrial fibrillation or intracardiac thrombus 2
• When LMWH is used, anti-Xa levels should be monitored 2

Procedural Interventions

• Implantation of permanent pacemakers or ICDs (preferably one chamber) should be considered with echocardiographical guidance, especially if the fetus is beyond 8 weeks gestation 1, 2
• Catheter ablation may be considered in cases of drug-refractory and poorly tolerated tachycardias 1, 2

Postpartum Considerations

• Methyldopa should be avoided post-partum due to risk of postnatal depression 1
• Some ACE inhibitors (benazepril, captopril, enalapril) can be safely used during breastfeeding 2
• Neonates whose mothers receive beta-blockers at parturition should be monitored for 24-48 hours after delivery 2

Monitoring Recommendations

• Close monitoring of fetal growth is warranted in women treated with beta-blockers 4
• For women on beta-blockers, monitor for potential neonatal hypoglycemia, bradycardia, and respiratory depression after delivery 2
• Regular BP control and monitoring of metabolic factors are recommended after delivery to reduce future cardiovascular risk 1