How should a 30‑week pregnant woman with systolic heart failure (ejection fraction ~30%) and NYHA class II dyspnea be managed, and which medications such as losartan, lisinopril, methyldopa, and hydralazine are appropriate?

Management of Heart Failure in Pregnancy at 30 Weeks

Immediately discontinue losartan and lisinopril—both are absolutely contraindicated in pregnancy and cause severe fetal harm—and initiate hydralazine plus nitrates for afterload reduction, combined with a β1-selective β-blocker (metoprolol, not atenolol) and diuretics for symptomatic relief. 1, 2, 3

Critical Medication Decisions

Absolutely Contraindicated Drugs

• Losartan and lisinopril must be stopped immediately. Both are FDA Pregnancy Category D drugs that act on the renin-angiotensin system and cause fetal renal dysgenesis, oligohydramnios, skull hypoplasia, anuria, hypotension, renal failure, and fetal death when used in the second and third trimesters. 2, 3
• ACE inhibitors, ARBs, and renin inhibitors are contraindicated throughout pregnancy due to fetotoxicity and must never be used. 1
• Atenolol should never be prescribed because it causes fetal growth restriction and intrauterine growth retardation. 1, 4
• Aldosterone antagonists (spironolactone, eplerenone) should be avoided—spironolactone has anti-androgenic effects in the first trimester and data on eplerenone are insufficient. 1, 4

Recommended Medications

First-line therapy:

• Hydralazine combined with nitrates is the preferred afterload-reducing regimen to substitute for ACE inhibitors/ARBs during pregnancy. 1, 4
• β1-selective β-blockers (metoprolol or propranolol) are recommended for all pregnant patients with heart failure when tolerated; these are first-line therapy according to the European Society of Cardiology. 1, 4
• Loop diuretics (furosemide) or thiazide diuretics (hydrochlorothiazide) should be used only when pulmonary congestion is present to relieve dyspnea, but avoid over-diuresis to preserve uteroplacental perfusion. 1, 4

Methyldopa is not indicated for heart failure management—it is an antihypertensive agent used for chronic hypertension in pregnancy, not for afterload reduction in systolic heart failure. 1

Risk Stratification

• Your patient's LVEF of 30% places her in the high-risk category (LVEF <40% is a predictor of maternal cardiovascular events), mandating close monitoring in a tertiary cardiac center with multidisciplinary cardio-obstetrics expertise. 1, 4
• NYHA Class II symptoms indicate moderate functional limitation but are manageable with optimal medical therapy. 1

Anticoagulation Management

• Therapeutic anticoagulation with low-molecular-weight heparin (LMWH) should be strongly considered because patients with severely reduced ejection fraction have heightened risk of ventricular thrombus and systemic embolism in the hypercoagulable peripartum state. 1, 4
• Anticoagulation is mandatory if any of the following develop: intracardiac thrombus on imaging, documented systemic embolism, or atrial fibrillation (paroxysmal or persistent). 1, 4
• When LMWH is used, monitor anti-Xa activity to ensure therapeutic levels. 1, 4

Monitoring Requirements

• Newborns of mothers receiving β-blockers require 24–48 hour monitoring for hypoglycemia, bradycardia, and respiratory depression after delivery. 1, 4
• Continuous hemodynamic monitoring is required throughout labor and delivery to detect decompensation promptly. 4
• Close surveillance with echocardiography and clinical assessment should occur regularly throughout the remainder of pregnancy. 1

Delivery Planning

• Vaginal delivery is preferred for hemodynamically stable patients without obstetric contraindications. 1, 4
• Epidural analgesia is the recommended method of pain control during labor. 1, 4
• Oxytocin (Syntocinon) should be administered as a slow infusion because rapid bolus can provoke hypotension, arrhythmias, and tachycardia; intravenous fluids must be given judiciously to avoid volume overload. 4
• Urgent delivery irrespective of gestation should be considered if the patient develops severe decompensated heart failure with hemodynamic instability—maternal stabilization is essential for fetal survival. 1, 4

Post-Delivery Management

• After delivery and once hemodynamically stable, standard heart-failure therapy (including ACE inhibitors) may be re-initiated. 1, 4
• For breastfeeding mothers, ACE inhibitors such as benazepril, captopril, or enalapril are considered safe for the infant. 1, 4
• Resume anticoagulation after postpartum bleeding has ceased. 1, 4

Common Pitfalls to Avoid

• Do not continue ACE inhibitors or ARBs "because the patient is already on them"—the fetal risk is catastrophic and these must be stopped immediately. 2, 3
• Do not prescribe atenolol thinking "all β-blockers are the same"—only β1-selective agents (metoprolol, propranolol) should be used. 1, 4
• Do not aggressively diurese to "dry out" the patient—this compromises placental perfusion and can harm the fetus. 1, 4
• Do not delay involving a multidisciplinary cardio-obstetrics team—high-risk patients require specialist center management. 1

Additional Supportive Measures

• If inotropic support becomes necessary, dopamine or levosimendan may be employed safely during pregnancy. 1
• Calcium channel blockers should be avoided if systolic heart failure is present. 5, 6