What is the appropriate management for a patient with peripartum cardiomyopathy and New York Heart Association (NYHA) class II symptoms who is currently on Metyldopa, Hydralazine, Lisinopril, and Heparin?

Management of Peripartum Cardiomyopathy NYHA Class II

Lisinopril must be discontinued immediately if the patient is still pregnant, as ACE inhibitors are absolutely contraindicated during pregnancy due to severe fetal renal toxicity and teratogenicity. 1, 2 If the patient has already delivered, lisinopril should be continued or initiated as part of standard heart failure therapy. 2

Critical Medication Assessment Based on Pregnancy Status

If Still Pregnant (Antepartum):

STOP Lisinopril immediately - ACE inhibitors cause serious fetal renal and other toxicity and are FDA Category D. 1, 2 This is non-negotiable regardless of heart failure severity.

Current appropriate medications:

• Methyldopa: Safe antihypertensive during pregnancy, continue 1
• Hydralazine: Appropriate vasodilator for peripartum cardiomyopathy during pregnancy, continue 1, 2
• Heparin: Appropriate anticoagulation if LVEF < 35%, continue 1, 2

Add the following:

• Beta-1 selective beta-blocker (metoprolol or bisoprolol): Safe during pregnancy and essential for heart failure management 1, 2
• Long-acting nitrates: Should be combined with hydralazine to replace ACE inhibitor effect 1, 2
• Diuretics (furosemide): Only if pulmonary congestion is present, use sparingly as they decrease placental blood flow 1, 2

If Postpartum (After Delivery):

CONTINUE Lisinopril - ACE inhibitors are the cornerstone of postpartum peripartum cardiomyopathy management and improve mortality. 2 Several ACE inhibitors (captopril, enalapril, quinapril) are safe during breastfeeding. 1

Current appropriate medications:

• Lisinopril: Continue as standard heart failure therapy 2
• Hydralazine: Can continue but less critical postpartum 1
• Heparin: Continue if LVEF < 35%, transition timing based on bleeding risk 1

Optimize the following:

• Beta-blocker: Ensure adequate dosing of beta-1 selective agent 1, 2
• Diuretics: Adjust based on volume status 1
• Consider bromocriptine: If LVEF < 35%, bromocriptine 2.5 mg twice daily for 2 weeks, then 2.5 mg daily for 4 weeks may enhance cardiac recovery (LVEF improvement from 27% to 58% at 6 months vs 27% to 36% with standard care) 1, 2 Must use therapeutic anticoagulation with bromocriptine due to thrombosis risk. 1, 2

Anticoagulation Strategy

Heparin is appropriate if LVEF < 35% due to high thromboembolism risk in peripartum cardiomyopathy. 1, 2 Use unfractionated or low-molecular-weight heparin during pregnancy. 1 Warfarin should be avoided during pregnancy due to fetotoxicity. 1

Additional Management Considerations

Avoid spironolactone during pregnancy - has anti-androgenic effects in first trimester. 1, 2

Defer ICD placement for at least 6 months - approximately 50% of peripartum cardiomyopathy patients show substantial improvement or normalization of LV function within this timeframe. 1, 2 ICD is only indicated if severe LV dysfunction persists at 6 months despite optimal medical therapy. 1

Breastfeeding counseling - discourage breastfeeding based on postulated negative effects of prolactin, though this is not fully evidence-based. 1 If bromocriptine is used, breastfeeding must be stopped. 1

Common Pitfalls to Avoid

Do not over-diurese - excessive diuresis compromises placental perfusion during pregnancy. 1, 2

Do not use methyldopa postpartum - it is only indicated for pregnancy-related hypertension and should be discontinued after delivery. 1

Do not delay ACE inhibitor initiation postpartum - immediate transition to ACE inhibitors after delivery improves outcomes. 2