73
During Pregnancy Postpartum
Close monitoring of maternal blood
pressure, heart rate, and volume status,
with adjustment of the modified
HF regimen as appropriate to avoid
hypotension (systemic vasodilation peaks
in the second trimester) and placental
hypoperfusion.
For women with HF or cardiomyopathy
presenting during pregnancy without
preconception counseling and assessment,
urgent discontinuation of any GDMT
pharmacotherapies with fetal toxicities;
within a construct of multidisciplinary
shared decision-making, continuation of a
beta blocker (most commonly metoprolol
succinate), hydralazine, and nitrates;
adjustment of diuretic dosing to minimize
the risk of placental hypoperfusion.
For women with acute HF caused by
PPCM and LVEF <30%, consideration of
anticoagulation until 6–8 wk postpartum,
although the efficacy and safety remain
uncertain at this time.
For postpartum women with severe
acute HF caused by PPCM and LVEF
<35%, in GDMT pharmacotherapy
and prophylactic anticoagulation, to
improve LVEF recovery (6,31,36-41,76);
the efficacy and safety of bromocriptine
for acute PPCM treatment remains
uncertain at this time, particularly in the
setting of contemporary HF GDMT and
cardiogenic shock management.*
For women who choose to breastfeed,
review medications with neonatolog y
and pediatrics teams for neonatal safety
during lactation, ideally with pharmacist
consultation if available.
Within a construct of multidisciplinary
shared decision-making, medications that
may be appropriate during breastfeeding
include ACEi (enalapril or captopril
preferred, monitor neonatal weight), beta
blockers (metoprolol preferred, monitor
neonatal heart rate).
Diuretics can suppress lactation, but with
neonatal follow-up the use of furosemide
may be appropriate.
Multidisciplinary management with
obstetrics and maternal-fetal medicine
teams during pregnancy.
For women with decompensated HF
or evidence of hemodynamic instability
antepartum, delivery planning will include
obstetrics and maternal-fetal medicine,
anesthesia, and neonatolog y teams.
Multidisciplinary management with
obstetrics, maternal-fetal medicine,
neonatolog y, and pediatrics teams,
especially for multidisciplinary
recommendations regarding lactation.
Consultation with g ynecolog y team for
ongoing contraceptive planning.
