Medication Management for Peripartum Cardiomyopathy at 25 Weeks Gestation
For a pregnant woman at 25 weeks with peripartum cardiomyopathy, use hydralazine combined with long-acting nitrates for afterload reduction, β1-selective beta-blockers (metoprolol), diuretics only if pulmonary congestion is present, and anticoagulation with low-molecular-weight heparin if ejection fraction is below 35%. 1
Contraindicated Medications During Pregnancy
ACE inhibitors, ARBs, and renin inhibitors are absolutely contraindicated due to serious fetal renal toxicity and teratogenicity. 1, 2 These medications cause fetal kidney damage and must never be used regardless of heart failure severity during pregnancy. 2
Aldosterone antagonists (spironolactone, eplerenone) should be avoided during pregnancy due to anti-androgenic effects in the first trimester and lack of safety data. 1, 2
Atenolol should not be used as the beta-blocker choice. 1, 3
Safe Medications During Pregnancy
Afterload Reduction
Hydralazine combined with long-acting nitrates is the safe alternative to ACE inhibitors/ARBs for afterload reduction during pregnancy. 1, 2 This combination provides vasodilation without teratogenic risks. 2
Beta-Blockers
β1-selective beta-blockers, specifically metoprolol, are safe and indicated for all patients with heart failure if tolerated. 1, 2, 3 β1-selective agents are preferred because β2 receptor blockade can theoretically have anti-tocolytic effects. 1
Monitor the newborn for 24-48 hours after delivery to exclude hypoglycemia, bradycardia, and respiratory depression if the mother received beta-blockers. 1, 3
Diuretics
Use diuretics sparingly and only if pulmonary congestion is present, as they can decrease placental blood flow. 1, 2
Furosemide and hydrochlorothiazide are the most frequently used diuretics when needed. 1, 2
Anticoagulation
Anticoagulation with unfractionated heparin or low-molecular-weight heparin should be considered if LVEF is below 35% due to the high thromboembolism risk in PPCM. 1, 2, 3 PPCM is a pro-thrombotic condition with increased risk of ventricular thrombi, cerebral embolism, and peripheral embolism. 1, 3
Monitor anti-Xa levels when using LMWH. 1, 3
Warfarin is contraindicated during pregnancy due to fetotoxicity. 1, 2
Inotropic Support (If Needed for Acute Decompensation)
Dopamine and levosimendan can be used if inotropic drugs are needed for signs of hypoperfusion or persistent congestion despite vasodilators and diuretics. 1, 3
Post-Delivery Medication Changes
Immediately after delivery, transition to standard heart failure therapy including ACE inhibitors or ARBs, continuing beta-blockers, and adding aldosterone antagonists. 1, 4, 2, 3
For breastfeeding women requiring ACE inhibitors, use benazepril, captopril, or enalapril, which have been adequately tested and are safe for babies. 1, 4
Bromocriptine may be considered for 2-8 weeks postpartum if LVEF remains below 35% to enhance cardiac recovery, but requires therapeutic anticoagulation due to increased thrombosis risk. 4, 2, 5 Data show LVEF recovery from 27% to 58% at 6 months with bromocriptine versus 27% to 36% with standard care alone. 4, 2
Critical Management Considerations
Joint cardiac and obstetric care is essential for women presenting with PPCM during pregnancy. 1
Urgent delivery regardless of gestational age may be necessary if the patient presents with or remains in advanced heart failure with hemodynamic instability. 1, 3
Approximately 50% of PPCM patients show spontaneous recovery within the first 6 months after diagnosis, which is important when making decisions about advanced therapies. 1, 4, 3
Avoid over-diuresis as it can compromise placental perfusion. 2