How should I manage a 30‑week‑gestation pregnant woman with symptomatic heart failure (ejection fraction ~30%, NYHA class II dyspnea) who is currently taking losartan, lisinopril, methyldopa, and hydralazine?

Management of Heart Failure in a 30-Week Pregnant Woman

Immediately discontinue losartan and lisinopril—both are absolutely contraindicated in pregnancy due to severe fetotoxicity—and replace them with hydralazine plus long-acting nitrates for afterload reduction, while continuing methyldopa and adding a beta-1 selective beta-blocker (metoprolol, not atenolol) for standard heart failure therapy. 1

Critical Medication Changes Required Now

Contraindicated Medications to Stop Immediately

• ACE inhibitors (lisinopril) and angiotensin receptor blockers (losartan) are absolutely contraindicated during the second and third trimesters because they cause renal dysgenesis, oligohydramnios, and severe fetotoxicity. 1
• These medications must be discontinued immediately at 30 weeks gestation to prevent irreversible fetal renal damage. 1

Safe Afterload Reduction Alternatives

• Hydralazine combined with long-acting nitrates should replace ACE inhibitors/ARBs for afterload reduction in pregnancy-related heart failure. 1
• Hydralazine dosing ranges from 750 mg to 4 g per day in three or four divided doses. 1
• This combination is the standard pregnancy-safe substitute when renin-angiotensin system blockade is contraindicated. 1

Continue and Optimize Current Safe Medications

• Methyldopa can be continued during pregnancy as it has extensive safety data, though it should be switched postpartum due to depression risk. 1, 2
• Hydralazine is already part of the regimen and should be continued at appropriate doses. 1

Essential Heart Failure Therapy to Add

Beta-Blocker Therapy

• Beta-1 selective beta-blockers (metoprolol) are indicated for all heart failure patients if tolerated, even during pregnancy. 1
• Atenolol must be specifically avoided due to associations with fetal growth restriction. 1
• Labetalol (an alpha-beta blocker with vasodilation properties) is an alternative, dosed 100 mg twice daily up to 2400 mg per day. 1
• Newborns require 24-48 hour supervision after delivery to exclude hypoglycemia, bradycardia, and respiratory depression. 1

Diuretic Management for NYHA Class II Symptoms

• Diuretics should only be used if pulmonary congestion is present, as they may decrease placental blood flow. 1
• For symptomatic dyspnea with evidence of fluid overload, furosemide or hydrochlorothiazide are the most frequently used and safest options. 1
• Loop diuretics (furosemide) have been used safely in pregnancy complicated by cardiac failure. 1
• Avoid diuretics if the patient is euvolemic, as they can reduce uteroplacental perfusion. 1

Anticoagulation Considerations

Thromboembolism Prevention

• With an ejection fraction of 30%, anticoagulation with low-molecular-weight heparin (LMWH) should be strongly considered due to increased thromboembolic risk. 1
• Coagulation activity is increased during pregnancy, and reduced EF significantly raises the risk of intracardiac thrombus and systemic embolism. 1
• LMWH is preferred during pregnancy; anti-Xa levels should be monitored. 1
• Anticoagulation is mandatory if imaging detects intracardiac thrombus, evidence of systemic embolism exists, or atrial fibrillation develops. 1

Delivery Planning and Monitoring

Mode of Delivery

• Vaginal delivery is always preferable if the patient is hemodynamically stable (currently NYHA class II) and there are no obstetric indications for cesarean section. 1
• Close hemodynamic monitoring is required throughout labor and delivery. 1
• Epidural analgesia is the preferred method for pain control. 1

Urgent Delivery Considerations

• Urgent delivery irrespective of gestation duration should be considered if the patient develops hemodynamic instability, worsening heart failure symptoms, or evidence of end-organ dysfunction. 1
• If gestation is less than 34 weeks and urgent delivery becomes necessary, steroids should be given for 48 hours to accelerate fetal lung maturation. 1

Advanced Therapies if Medical Management Fails

Inotropic Support

• If inotropic drugs are needed for hemodynamic support, dopamine and levosimendan can be used safely during pregnancy. 1

Mechanical Support and Transplantation

• If the patient becomes dependent on inotropes despite optimal medical therapy, transfer to a facility with intra-aortic balloon pump counterpulsation, ventricular assist devices, and transplant teams is essential. 1
• The prognosis of peripartum cardiomyopathy differs from dilated cardiomyopathy, with up to 50% showing spontaneous recovery over the first 6 months—this must be considered before irreversible interventions. 1

Critical Pitfalls to Avoid

• Never continue ACE inhibitors or ARBs beyond the first trimester—the fetotoxic effects are especially pronounced during the second and third trimesters. 1
• Do not add spironolactone or other mineralocorticoid receptor antagonists during pregnancy due to antiandrogenic effects in the first trimester and lack of safety data. 1, 3
• Avoid using diuretics aggressively in the absence of clear pulmonary congestion, as they reduce plasma volume expansion and may compromise uteroplacental circulation. 1
• Do not use atenolol as the beta-blocker of choice—it is specifically associated with fetal growth restriction. 1

Postpartum Medication Adjustments

• Once the baby is delivered and the patient is hemodynamically stable, standard heart failure therapy can be fully applied. 1
• Transition from hydralazine/nitrates back to ACE inhibitors (benazepril, captopril, or enalapril are preferred during breastfeeding). 1
• Switch methyldopa to an alternative agent postpartum due to its association with postpartum depression. 2
• Continue anticoagulation therapy carefully in the immediate postpartum phase, resuming once bleeding has stopped. 1