What is the most appropriate treatment for a patient at 30 weeks of gestation with peripartum cardiomyopathy, reduced ejection fraction (EF), and New York Heart Association (NYHA) class II symptoms?

Treatment of Peripartum Cardiomyopathy at 30 Weeks Gestation

The most appropriate treatment is C. Hydralazine (in combination with nitrates for afterload reduction), as ACE inhibitors and ARBs are absolutely contraindicated during pregnancy due to serious fetal renal toxicity and teratogenicity. 1, 2

Why ACE Inhibitors and ARBs Are Contraindicated

• ACE inhibitors and ARBs must never be used during pregnancy regardless of heart failure severity, as they cause serious fetal renal toxicity, oligohydramnios, intrauterine growth restriction, and skeletal malformations 1, 2
• These agents are FDA Category D drugs, meaning there is positive evidence of human fetal risk 2
• The fetal harm from ACE inhibitors/ARBs far outweighs any maternal cardiovascular benefit during pregnancy 1, 2

Why Hydralazine Is the Correct Choice

• Hydralazine combined with long-acting nitrates is the recommended safe alternative to ACE inhibitors/ARBs for afterload reduction in pregnant patients with peripartum cardiomyopathy 1, 2
• This combination provides effective vasodilation without the teratogenic risks associated with renin-angiotensin system blockade 2
• European Society of Cardiology guidelines specifically recommend hydralazine as the preferred option during pregnancy 2

Why Methyldopa Is Incorrect

• Methyldopa is an antihypertensive used for chronic hypertension in pregnancy, but it does not provide the afterload reduction needed for heart failure management in peripartum cardiomyopathy 1
• It lacks the evidence base for treating reduced ejection fraction heart failure that hydralazine-nitrate combination possesses 2

Complete Management Algorithm for This Patient

Immediate Pharmacologic Therapy (at 30 weeks gestation):

• Hydralazine plus long-acting nitrates for afterload reduction 1, 2
• Beta-1 selective beta-blocker (metoprolol preferred, NOT atenolol) for all heart failure patients if tolerated 1, 2
• Diuretics (furosemide or hydrochlorothiazide) only if pulmonary congestion is present, used sparingly to avoid decreased placental blood flow 1, 2
• Avoid aldosterone antagonists (spironolactone has anti-androgenic effects in first trimester; eplerenone lacks safety data) 1, 2

Anticoagulation Considerations:

• Consider anticoagulation with unfractionated or low-molecular-weight heparin if LVEF <35% due to high thromboembolism risk in peripartum cardiomyopathy 1, 2
• Warfarin should be avoided during pregnancy due to fetotoxicity 1
• Monitor anti-Xa levels if using LMWH 1

Post-Delivery Management (Critical Transition):

• Immediately after delivery and hemodynamic stability, switch to standard heart failure therapy including ACE inhibitors (captopril, enalapril, or benazepril preferred for breastfeeding) 1, 2
• Continue beta-blocker therapy 1, 2
• Consider bromocriptine 2.5 mg twice daily for 2 weeks, then 2.5 mg daily for 4-6 weeks if LVEF <35% to enhance cardiac recovery, but requires therapeutic anticoagulation due to increased thrombosis risk 1, 2

Critical Pitfalls to Avoid

• Never initiate ACE inhibitors or ARBs during pregnancy even if heart failure worsens—the fetal risks are unacceptable 1, 2
• Avoid over-diuresis as it compromises placental perfusion and can harm the fetus 1, 2
• Do not use atenolol as the beta-blocker choice—metoprolol is preferred 1
• Defer ICD placement for at least 6 months as approximately 50% of peripartum cardiomyopathy patients show substantial improvement or normalization of LV function within this timeframe 1, 2

Delivery Planning

• Vaginal delivery is preferable if hemodynamically stable with no obstetric contraindications 1
• Epidural analgesia is preferred as it stabilizes cardiac output 1
• Urgent delivery regardless of gestational age should be considered if the patient remains in advanced heart failure with hemodynamic instability 1