What is the most appropriate treatment for a pregnant patient at 30 weeks of gestation with peripartum cardiomyopathy, reduced ejection fraction (EF) of 48%, and symptoms of shortness of breath (SOB) classified as New York Heart Association (NYHA) class II?

Treatment of Peripartum Cardiomyopathy at 30 Weeks Gestation

The most appropriate treatment is C. Hydralazine, as ACE inhibitors (Lisinopril) and ARBs (Losartan) are absolutely contraindicated during pregnancy due to fetotoxicity, and methyldopa is not indicated for heart failure management. 1, 2

Why ACE Inhibitors and ARBs Are Contraindicated

• ACE inhibitors (Lisinopril) and ARBs (Losartan) cause serious fetal harm including renal dysgenesis, oligohydramnios, intrauterine growth restriction, skull hypoplasia, and fetal death when used during pregnancy. 1, 2
• The European Society of Cardiology explicitly states that ACE inhibitors, ARBs, and renin inhibitors are contraindicated during pregnancy because of fetotoxicity. 1
• These agents are FDA Category D, meaning there is positive evidence of human fetal risk. 2

Why Hydralazine Is the Correct Choice

• Hydralazine (combined with nitrates) is the recommended alternative to ACE inhibitors/ARBs for afterload reduction during pregnancy in patients with peripartum cardiomyopathy. 1, 2
• The European Society of Cardiology guidelines specifically recommend hydralazine and nitrates as safe alternatives for vasodilation without teratogenic risks. 1, 2
• This combination provides effective afterload reduction while avoiding fetal harm. 2

Why Methyldopa Is Inappropriate

• Methyldopa is an antihypertensive agent used for chronic hypertension in pregnancy, not for heart failure management. 2
• It does not provide the afterload reduction or neurohormonal blockade needed for peripartum cardiomyopathy with reduced ejection fraction. 2
• While safe in pregnancy, it is simply the wrong drug class for this clinical scenario.

Complete Management Algorithm for This Patient

Immediate Pharmacological Therapy (at 30 weeks gestation):

• Start hydralazine with long-acting nitrates for afterload reduction as first-line therapy. 1, 2
• Initiate beta-1 selective beta-blocker (metoprolol) as beta-blockers are indicated for all heart failure patients if tolerated; avoid atenolol. 1, 2
• Add diuretics (furosemide or hydrochlorothiazide) only if pulmonary congestion is present, as they may decrease placental blood flow. 1, 2
• Consider anticoagulation with low-molecular-weight heparin given the EF of 48% (some guidelines suggest considering anticoagulation when EF <35%, but thromboembolism risk is elevated in all PPCM). 1

Critical Monitoring Points:

• Joint cardiac and obstetric care is mandatory for this patient who remains pregnant. 1
• Monitor for hemodynamic deterioration that might necessitate urgent delivery regardless of gestational age. 1
• Newborns should be supervised for 24-48 hours after delivery to exclude hypoglycemia, bradycardia, and respiratory depression from beta-blocker exposure. 1

Post-Delivery Management Transition:

• Immediately after delivery and once hemodynamically stable, switch to standard heart failure therapy including ACE inhibitors (captopril, enalapril, or benazepril are preferred during breastfeeding). 1, 2
• Continue beta-blocker therapy postpartum. 2
• Consider bromocriptine for 2-8 weeks postpartum if LVEF remains <35% to enhance cardiac recovery, but this requires therapeutic anticoagulation due to thrombosis risk. 2

Common Pitfalls to Avoid

• Never use ACE inhibitors or ARBs during pregnancy regardless of heart failure severity - the fetal risks are unacceptable. 1, 2
• Avoid spironolactone during pregnancy due to antiandrogenic effects in the first trimester. 1, 3
• Do not over-diurese as this compromises placental perfusion. 2
• Defer ICD placement for at least 6 months as approximately 50% of PPCM patients show substantial improvement or normalization of LV function within this timeframe. 1, 2

Prognosis Considerations

• The American College of Cardiology reports 93% transplant/LVAD-free 1-year survival in developed countries. 1
• Approximately 50% of patients experience spontaneous recovery of LV function within the first 6 months. 1
• Recovery is related to initial LVEF, with this patient's EF of 48% suggesting a relatively favorable prognosis. 1