Management of heart failure during pregnancy
- Jeanne M DeCara, MD
Jeanne M DeCara, MD
- Associate Professor of Medicine
- Pritzker School of Medicine of the University of Chicago
- Roberto M Lang, MD
Roberto M Lang, MD
- Professor of Medicine
- Pritzker School of Medicine of the University of Chicago
- Michael R Foley, MD
Michael R Foley, MD
- University of Arizona College of Medicine - Phoenix
- Section Editors
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
Pregnancy is associated with substantial hemodynamic changes, including 30 to 50 percent increases in both cardiac output and blood volume. In women with a history of heart failure (HF) or other cardiovascular disorders, these demands can lead to clinical decompensation. In addition, women without a history of cardiovascular disease can develop HF due to diseases acquired during pregnancy, such as peripartum cardiomyopathy. (See "Maternal adaptations to pregnancy: Cardiovascular and hemodynamic changes" and "Peripartum cardiomyopathy: Etiology, clinical manifestations, and diagnosis".)
HF is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. It is characterized by specific symptoms, such as dyspnea and fatigue, and signs, such as fluid retention. (See "Evaluation of the patient with suspected heart failure".)
Because of concerns related to potential adverse effects on the fetus and the mother, medication use to treat HF during pregnancy is challenging. This is an important issue in women with both chronic and acute HF. For example, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and angiotensin receptor-neprilysin inhibitor which are part of the standard long-term therapeutic regimen in nonpregnant patients with HF with reduced ejection fraction, are contraindicated during pregnancy. (See "Angiotensin converting enzyme inhibitors and receptor blockers in pregnancy".)
Management of women with HF who are breastfeeding requires consideration of the levels of drugs in breast milk with possible adverse effects in the nursing infant as well as potential effects of medications on lactation.
The evaluation and management of HF during pregnancy and breastfeeding will be reviewed here. The general approach to pregnancy in women with known congenital or acquired heart disease, treatment of peripartum cardiomyopathy, treatment of hypertrophic cardiomyopathy during pregnancy, and overviews of the management of acute and chronic HF are presented separately. (See "Acquired heart disease and pregnancy" and "Pregnancy in women with congenital heart disease: General principles" and "Peripartum cardiomyopathy: Treatment and prognosis" and "Treatment of acute decompensated heart failure: General considerations" and "Overview of the therapy of heart failure with reduced ejection fraction" and "Hypertrophic cardiomyopathy: Medical therapy", section on 'HCM during pregnancy and delivery'.)
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- CATEGORIES OF HEART FAILURE
- Chronic versus acute conditions
- Types of heart failure
- Stable patient
- New or acute heart failure
- Differential diagnosis
- MANAGEMENT GOALS
- TREATMENT REGIMENS
- Systolic versus diastolic heart failure
- Chronic heart failure
- Acute heart failure
- Refractory heart failure
- Avoid angiotensin inhibition
- Beta blockers
- - During pregnancy
- - During nursing
- - Hydralazine plus nitrate
- - Intravenous agents
- Nitroglycerin or nitroprusside
- Aldosterone antagonists
- SUMMARY AND RECOMMENDATIONS
- Evaluation of HF during pregnancy
- Treatment of HF during pregnancy
- - Treatment regimens
- - Drugs to avoid during pregnancy
- - Anticoagulation