What is the most appropriate treatment for a pregnant patient at 30 weeks of gestation with peripartum cardiomyopathy, reduced ejection fraction (EF), and 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 in peripartum cardiomyopathy.

Why Hydralazine is the Correct Choice

Hydralazine (combined with nitrates) is the recommended vasodilator for afterload reduction in pregnant patients with peripartum cardiomyopathy because it provides the hemodynamic benefits needed for heart failure management without the teratogenic risks of renin-angiotensin system blockade. 1, 2

• The European Society of Cardiology guidelines explicitly state that hydralazine and nitrates should be used instead of ACE inhibitors/ARBs for afterload reduction during pregnancy 1
• This recommendation is based on the need to manage reduced ejection fraction and heart failure symptoms while avoiding fetal harm 1, 2

Why the Other Options Are Incorrect

Losartan (ARB) and Lisinopril (ACE Inhibitor) - Absolutely Contraindicated

ACE inhibitors, ARBs, and renin inhibitors are contraindicated during pregnancy because of fetotoxicity, including fetal renal dysfunction, oligohydramnios, intrauterine growth restriction, and skeletal malformations. 1, 2

• These medications are FDA Category D, meaning there is positive evidence of human fetal risk 2
• The 2022 AHA/ACC/HFSA guidelines explicitly state these agents should not be administered during pregnancy because of significant risks of fetal harm 1
• This contraindication applies regardless of heart failure severity - the fetal risks are unacceptable 2

Methyldopa - Wrong Indication

Methyldopa is an antihypertensive agent used for chronic hypertension in pregnancy, but it has no role in managing heart failure with reduced ejection fraction 2. It does not provide afterload reduction adequate for heart failure management and does not address the pathophysiology of peripartum cardiomyopathy.

Complete Management Algorithm for This Patient

Immediate Pharmacological Therapy (During Pregnancy)

1. Hydralazine + nitrates for afterload reduction 1, 2
2. Beta-1 selective beta-blocker (metoprolol, NOT atenolol) if tolerated for all heart failure patients 1, 2
3. Diuretics (furosemide or hydrochlorothiazide) ONLY if pulmonary congestion is present, used sparingly as they can decrease placental blood flow 1, 2
4. Anticoagulation with low-molecular-weight heparin should be considered given the reduced ejection fraction and increased thromboembolism risk during pregnancy 1, 2

Critical Monitoring Considerations

• Newborns should be supervised for 24-48 hours after delivery to exclude hypoglycemia, bradycardia, and respiratory depression from beta-blocker exposure 1
• Avoid aldosterone antagonists (spironolactone) due to anti-androgenic effects in the first trimester 1, 2
• Monitor for signs of hemodynamic instability that might necessitate urgent delivery regardless of gestational age 1

Post-Delivery Management Transition

Once the baby is delivered and the patient is hemodynamically stable, immediately transition to standard heart failure therapy including ACE inhibitors (captopril, enalapril, or benazepril are safe during breastfeeding). 1, 2

• Bromocriptine may be considered for 2-8 weeks postpartum if LVEF remains <35% to enhance cardiac recovery, but requires therapeutic anticoagulation due to increased thrombosis risk 1, 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

Common Pitfalls to Avoid

• Never use ACE inhibitors or ARBs during pregnancy, even in severe heart failure - the fetal risks outweigh any maternal benefit 1, 2
• Avoid over-diuresis as it compromises placental perfusion 2
• Do not use atenolol as the beta-blocker choice - use beta-1 selective agents like metoprolol 1
• Do not delay delivery if the patient remains in advanced heart failure with hemodynamic instability despite medical therapy 1