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 cardiovascular and hemodynamic adaptations to pregnancy" 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'.)
- Siu SC, Colman JM. Heart disease and pregnancy. Heart 2001; 85:710.
- Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001; 104:515.
- Drenthen W, Pieper PG, Roos-Hesselink JW, et al. Outcome of pregnancy in women with congenital heart disease: a literature review. J Am Coll Cardiol 2007; 49:2303.
- Lang RM, Borow KM. Heart disease. In: Medical Disorders During Pregnancy, 3rd ed, Barron WM, Lindheimer MD (Eds), Mosby Inc, St. Louis 2000. p.180.
- Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:1810.
- Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010; 12:767.
- Tanous D, Siu SC, Mason J, et al. B-type natriuretic peptide in pregnant women with heart disease. J Am Coll Cardiol 2010; 56:1247.
- Hameed AB, Chan K, Ghamsary M, Elkayam U. Longitudinal changes in the B-type natriuretic peptide levels in normal pregnancy and postpartum. Clin Cardiol 2009; 32:E60.
- European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German Society for Gender Medicine (DGesGM), et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:3147.
- Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119:e391.
- McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33:1787.
- Sims DB, Vink J, Uriel N, et al. A successful pregnancy during mechanical circulatory device support. J Heart Lung Transplant 2011; 30:1065.
- Lee W. Clinical management of gravid women with peripartum cardiomyopathy. Obstet Gynecol Clin North Am 1991; 18:257.
- Alwan S, Polifka JE, Friedman JM. Angiotensin II receptor antagonist treatment during pregnancy. Birth Defects Res A Clin Mol Teratol 2005; 73:123.
- Lavoratti G, Seracini D, Fiorini P, et al. Neonatal anuria by ACE inhibitors during pregnancy. Nephron 1997; 76:235.
- Schubiger G, Flury G, Nussberger J. Enalapril for pregnancy-induced hypertension: acute renal failure in a neonate. Ann Intern Med 1988; 108:215.
- http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACTMED (Accessed on July 01, 2014).
- Easterling TR, Carr DB, Brateng D, et al. Treatment of hypertension in pregnancy: effect of atenolol on maternal disease, preterm delivery, and fetal growth. Obstet Gynecol 2001; 98:427.
- Bayliss H, Churchill D, Beevers M, Beevers DG. Anti-hypertensive drugs in pregnancy and fetal growth: evidence for "pharmacological programming" in the first trimester? Hypertens Pregnancy 2002; 21:161.
- Lydakis C, Lip GY, Beevers M, Beevers DG. Atenolol and fetal growth in pregnancies complicated by hypertension. Am J Hypertens 1999; 12:541.
- Beardmore KS, Morris JM, Gallery ED. Excretion of antihypertensive medication into human breast milk: a systematic review. Hypertens Pregnancy 2002; 21:85.
- Joglar JA, Page RL. Treatment of cardiac arrhythmias during pregnancy: safety considerations. Drug Saf 1999; 20:85.
- Widerhorn J, Rubin JN, Frishman WH, Elkayam U. Cardiovascular drugs in pregnancy. Cardiol Clin 1987; 5:651.
- Lees KR, Rubin PC. Treatment of cardiovascular diseases. Br Med J (Clin Res Ed) 1987; 294:358.
- King CR, Mattioli L, Goertz KK, Snodgrass W. Successful treatment of fetal supraventricular tachycardia with maternal digoxin therapy. Chest 1984; 85:573.
- Lindheimer MD, Katz AI. Sodium and diuretics in pregnancy. N Engl J Med 1973; 288:891.
- Vink GJ, Moodley J, Philpott RH. Effect of dihydralazine on the fetus in the treatment of maternal hypertension. Obstet Gynecol 1980; 55:519.
- Kuzniar J, Skret A, Piela A, et al. Hemodynamic effects of intravenous hydralazine in pregnant women with severe hypertension. Obstet Gynecol 1985; 66:453.
- Hall JB, Schmidt GA. Critical illness. In: Medical Disorders During Pregnancy, Barron WM, Lindheimer MD (Eds), Mosby Inc, St. Louis 2000. p.240.
- Palmer RF, Lasseter KC. Drug therapy. Sodium nitroprusside. N Engl J Med 1975; 292:294.
- O'Connor CM, Starling RC, Hernandez AF, et al. Effect of nesiritide in patients with acute decompensated heart failure. N Engl J Med 2011; 365:32.
- Gherman RB, Goodwin TM, Leung B, et al. Incidence, clinical characteristics, and timing of objectively diagnosed venous thromboembolism during pregnancy. Obstet Gynecol 1999; 94:730.
- Refuerzo JS, Hechtman JL, Redman ME, Whitty JE. Venous thromboembolism during pregnancy. Clinical suspicion warrants evaluation. J Reprod Med 2003; 48:767.
- 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