Cardio-Obstetrics and Heart Failure: Key Points

DeFilippis EM, Bhagra C, Casale J, et al.
Cardio-Obstetrics and Heart Failure: JACC: Heart Failure State-of-the-Art Review. JACC Heart Fail 2023;11:1165-1180.

The following are key points to remember from a state-of-the-art review on cardio-obstetrics and heart failure (HF):

  1. Peripartum cardiomyopathy is the most common cause of HF during pregnancy; however, many other types of cardiomyopathy are possible. During pregnancy, echocardiography and cardiac magnetic resonance imaging without gadolinium contrast may be helpful to distinguish potential etiologies.
  2. Hypertrophic cardiomyopathy is frequently tolerated during pregnancy, but complications include syncope, heart failure, atrial fibrillation, and ventricular tachycardia. Obstructive physiology may worsen due to decreased afterload, increased cardiac contractility, and increased heart rate during pregnancy.
  3. Arrhythmogenic right ventricular cardiomyopathy is associated with low rates of arrhythmic events during pregnancy. In one cohort, 23% of women died at median follow-up of 8 years post-partum.
  4. Left ventricular noncompaction may be confused with normal increase in trabeculation during pregnancy. Limited data are available and small studies have described peripartum cases of atrial fibrillation and cardiac arrest due to ventricular fibrillation.
  5. Contraception should be discussed with patients who are not currently desiring pregnancy. Acute heart failure and severe cardiomyopathy are relative contraindications to combined hormonal contraceptives due to thromboembolic risks; however, patient preference and adherence with alternative methods are important. Progestin intrauterine devices (IUDs) are the preferred option for patients with high-risk cardiac conditions.
  6. Emergency contraception (i.e., the copper IUD, and emergency contraceptive pills ulipristal acetate and levonorgestrel) may be safely used in high-risk HF patients.
  7. Medical therapy of HF during pregnancy include: beta-blockers, diuretics, digoxin, and inotropic support. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, angiotensin receptor/neprilysin inhibitors (ARNIs), mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 (SGLT2) inhibitors are contraindicated during pregnancy.
  8. Medical therapy of HF while breastfeeding includes: ACE inhibitors (enalapril, captopril, benazepril), spironolactone, beta-blockers, diuretics, and digoxin. ARNI and SGLT2 inhibitors do not have lactation data and are generally avoided with breastfeeding.
  9. Medical therapy of HF due to peripartum cardiomyopathy additionally includes:
    • Consideration of anticoagulation: An American Heart Association Scientific Statement gives moderate consensus, Level of Evidence C, for anticoagulation when the ejection fraction is <30% due to postpartum hypercoagulable state.
    • Bromocriptine is currently being studied in the randomized controlled study REBIRTH (NCT05180773), now enrolling patients in the United States and Canada.
  10. Although pregnancy is contraindicated for women with left ventricular assist device (LVAD), unplanned pregnancies still occur. In a review of nine pregnancies, there was one maternal death. LVAD speed may need to be increased during pregnancy to provide increased cardiac output. Specific guidelines for anticoagulation are lacking. Delivery needs to be planned with an expert multidisciplinary team.
  11. In select patients, pregnancy after heart transplantation can be considered. Contraindications to pregnancy include: <1 year post-transplant, reduced graft function, nonadherence, donor-specific antibodies, significant cardiac allograft vasculopathy, poorly controlled hypertension, diabetes, renal dysfunction, and active infection.
    • Mycophenolate mofetil and mycophenolic acid are teratogenic and need to be discontinued. Azathioprine may be used as a replacement.
    • Recommended monitoring includes echocardiogram every trimester and monthly after 24 weeks of gestation until delivery. Drug levels should be monitored during and after pregnancy due to changing plasma volume.
  12. The fourth trimester (12 weeks postpartum) is an important time frame for monitoring blood pressure, drug levels, volume changes, breastfeeding, medication optimization, mental health, contraception, and transitioning care teams.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Cardiomyopathies, Contraception, Heart Failure, Obstetrics, Pregnancy

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