Management
Compensated Heart Failure
Management of PPCM is similar to standard treatment for other forms of heart failure. However, no randomized clinical trials have been done to evaluate these therapies specifically in PPCM. Furthermore, careful attention should be paid to fetal safety and to excretion of drug or drug metabolites during breastfeeding after delivery. The goals in treating heart failure are to improve hemodynamic status, minimize signs and symptoms, and optimize the long-term outcomes. Treatment focuses on reducing preload and afterload and increasing cardiac inotropy. Pearson et al reinforce that collaboration among medical specialists, including obstetricians, cardiologists, perinatologists, and neonatologists, is essential in care of women with PPCM. Of note, polypharmacy may be required for optimal management, to slow progression of heart failure and to improve outcomes in women with left ventricular systolic dysfunction. Medications should be continued until evidence indicates improved and/or resolved left ventricular dysfunction. Women with PPCM should be treated in the hospital when they have evidence of hypotension, worsening heart failure, altered mental status, and increased work of breathing.
Preload reduction is accomplished by administration of vasodilators, such as nitrates, most of which are safe during pregnancy and breastfeeding. Loop diuretics are important for management of signs and symptoms and for preload reduction, although caution is warranted in antepartum women because rapid changes in intravascular volume can lead to a decrease in blood supply to the uterus and therefore the fetus. Restriction of dietary sodium is also helpful in preload reduction. Bed rest was once standard care but is no longer recommended because of the increased risk of thromboembolism. The current recommendation is light exercise such as walking.
Ideal medications intrapartum include hydralazine, nitrates, digoxin, and diuretics. Angiotensin-converting enzyme inhibitors are contraindicated during pregnancy because of their teratogenicity, but these medications are the mainstay of treatment of PPCM after delivery for afterload reduction. Safe alternatives during pregnancy include hydralazine and nitrates. Aldosterone antagonists have been effective when angiotensin-converting enzyme inhibitors were not tolerated, but the antagonists should not be used during pregnancy.
β-Adrenergic antagonists, such as extended-release metoprolol and carvedilol, have been approved for use in PCCM and can improve survival. However, β-blockers should not be given in the early stages of PPCM because they can decrease perfusion in the acute decompensated phase of the disease. Pearson et al have proposed that carvedilol be used in postpartum women who continue to have signs and symptoms of heart failure and have echocardiographic evidence of left ventricular compromise after more than 2 weeks of therapy. Digoxin, an inotropic agent, is also safe during pregnancy and should be considered for women with left ventricular systolic dysfunction and an ejection fraction of less than 40% who have signs and symptoms of heart failure while receiving standard therapy. Guidelines for management of compensated heart failure in PPCM are presented in Table 1.