Society for Maternal-Fetal Medicine Consult Series #73: Diagnosis and management of right and left heart failure during pregnancy and postpartum

Heart failure is a major contributor to maternal morbidity and mortality. Pregnancy is a state of hemodynamic stress, and normal physiologic changes of pregnancy may mimic signs of heart failure. Prepregnancy counseling, multidisciplinary care, and referral to a center with expertise in managing pregnant patients with heart failure can help optimize outcomes. The option for abortion care should be available to all patients with heart failure, regardless of the severity of the disease, and is an essential component of individualized counseling. In this Consult, we provide guidance for managing patients with heart failure with reduced ejection fraction who are continuing pregnancy. The following are Society for Maternal-Fetal Medicine (SMFM) recommendations: (1) we recommend that all patients with right heart failure due to pulmonary arterial hypertension receive counseling about high rates of maternal morbidity and mortality; if pregnancy is pursued, the patient should be referred to a center with expertise in this condition to guide management during pregnancy and postpartum (GRADE 1C); (2) we recommend considering referral to a genetics provider with expertise in heritable cardiac disease for people with peripartum cardiomyopathy (PPCM), particularly when the index of suspicion is high and no other contributing factors are identified (GRADE 1C); (3) we recommend that other causes of heart failure be ruled out before making a diagnosis of PPCM (Best Practice); (4) for acute left ventricular heart failure during pregnancy, we recommend hydralazine or isosorbide dinitrate for afterload reduction and furosemide for diuresis. For acute left ventricular failure postpartum, we recommend afterload reduction with angiotensin-converting enzyme inhibitor (ACEi), angiotensin receptor blocker (ARB), or angiotensin receptor/neprilysin inhibitor (ARNi) unless contraindicated (e.g., renal failure) (GRADE 1B); (5) we recommend against inotropic blockade (i.e., beta-blockers) in the setting of acute decompensated left ventricular heart failure (GRADE 1B); (6) we recommend prophylactic anticoagulation administration in hospitalized pregnant patients with acute left ventricular heart failure (GRADE 1C); (7) in patients who are pursuing pregnancy or pregnant, we recommend discontinuing spironolactone, ACEi, ARB, and ARNi and continuing beta-blockers (metoprolol, carvedilol, bisoprolol) (GRADE 1C); (8) for pregnant patients with left ventricular failure and ejection fraction < 35%, we recommend pharmacologic thromboprophylaxis during pregnancy and for six weeks postpartum (GRADE 1C); (9) for patients with chronic left ventricular failure, we recommend starting or continuing guideline-directed medical therapy when medically able, in consultation with experts in cardiology (GRADE 1C); (10) we recommend fetal echocardiography when maternal heart failure is a result of an underlying congenital cardiac defect (GRADE 1C); (11) we recommend serial growth ultrasounds in pregnancies complicated by maternal heart failure (GRADE 1C); (12) we recommend continuous fetal heart rate monitoring during anesthesia administration, labor, and delivery for pregnant patients with heart failure (GRADE 1B); (13) in the case of maternal cardiovascular changes prompting inpatient assessment or treatment, we recommend continuous or intermittent fetal heart rate monitoring, taking into consideration the gestational age and any relevant maternal or fetal factors that may impact fetal viability or the maternal clinical status (GRADE 1C); (14) we recommend planned vaginal delivery at term in patients with heart failure in the absence of hemodynamic compromise or obstetric indications for cesarean (GRADE 1C); (15) we recommend the use of neuraxial anesthesia in most patients with heart failure to provide appropriate analgesia and to limit the effects of labor on cardiac parameters (GRADE 1C); (16) we recommend considering a limited or assisted second stage for some patients after input from cardiology about each individual patient's cardiac risk (GRADE 1C); (17) we recommend that postpartum patients with heart failure undergo routine counseling regarding infant feeding. We recommend reviewing all medications for compatibility with breastfeeding and using shared decision-making in the absence of robust data (GRADE 1B).