Strategies proposed for managing pregnancy, delivery for people with heart failure
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Key takeaways:
- A new state-of-the-art review emphasizes shared decision-making for people with heart failure who become pregnant.
- Close follow-up after delivery can reduce the risk for serious complications.
Pregnancy brings risks for serious or even fatal complications for people of reproductive age with HF, and obstetricians and cardiologists should work together to ensure those risks are minimized, according to a new review.
For women living with HF or other serious CVDs, comprehensive care must begin with thorough preconception counseling that highlights the potential risks that come with pregnancy, according to Michelle M. Kittleson, MD, PhD, director of postgraduate medical education in heart failure and transplantation and professor of medicine in the Smidt Heart Institute at Cedars-Sinai. For some women with HF, pregnancy is an option when there is shared decision-making regarding the maternal and fetal risks of pregnancy and close management of medications, Kittleson said.
Healio spoke with Kittleson about the importance of preconception counseling for people with HF, working with a multidisciplinary team to ensure best outcomes, and how to avoid CV complications during the so-called “fourth trimester” after delivery. Kittleson and colleagues’ state-of-the-art review was recently published in JACC: Heart Failure.
Healio: Why is this review needed now?
Kittleson: We know that we do not do a great job caring for pregnant individuals across the world, especially in the U.S. Maternal mortality continues to rise and that is particularly true for women with CVD, which accounts for more than one-third of pregnancy-related deaths. Women with a cardiomyopathy have a greater risk for an adverse cardiac event, including in-hospital mortality — fourfold greater if you have a cardiomyopathy event compared with other types of CVD. This is a huge problem.
Second, we know many clinicians are not comfortable dealing with a pregnant individual with cardiac issues. We wrote this state-of-the-art review to serve as a “users guide” to help these clinicians navigate these areas. When is pregnancy safe? When is pregnancy not safe? What are the best contraceptive options to offer when you encounter a patient with HF? What medications are appropriate?
Healio: Let’s discuss preconception counseling. For people with childbearing potential with CVD, and especially HF, what do they need to know?
Kittleson: We have moved from a more paternalistic approach — I’ll tell you what to do — to shared decision-making, where the patient has a say in what is best for their body. We know there are high-risk features that place a patient and their unborn fetus at increased risk for adverse outcomes. We know the most important ones are pulmonary arterial hypertension, severe left ventricular dysfunction, previous peripartum cardiomyopathy with ongoing left ventricular dysfunction or a heart transplant. Those are the patients for whom we would counsel that the risk may be prohibitive and it is best to consider not ever getting pregnant and using reliable contraception, and, if there is an unplanned pregnancy, the role of termination. But this really comes down to shared decision-making. Absolutely, there are patients who say, “It is so important for me to bear this child.” You are then their partner in the high-risk journey, recognizing it may not end well.
This is not about telling patients, “You should never get pregnant” or “You need permanent contraception.” Instead, it is about, “I can tell you that medically this is not a great idea; tell me your thoughts.”
Medical termination is probably safest to avoid the risks of anesthesia, when indicated. However, when it comes to the political or legal overlay, it is very tricky. In these situations, the multidisciplinary team is so important for guidance on local limitations regarding termination. It is not about always knowing the right answer, but about asking the right questions.
Healio: You use the phrase high-risk journey. If a person with HF becomes pregnant, what are the unique management conditions?
Kittleson: That is a huge point. We know the importance of guideline-directed medical therapy, or GDMT, in patients with HF with reduced ejection fraction and also for patients with HF with preserved EF. We talk all the time until blue in the face about the use of ACE inhibitors, angiotensin receptor blockers, angiotensin receptor/neprilysin inhibitors (ARNIs), mineralocorticoid receptor antagonists (MRAs) and SGLT2 inhibitors. We have to throw much of what we know out the window with a pregnant individual with HF. We know beta-blockers are safe, predominantly metoprolol and bisoprolol have safety data and can and should be used. Diuretic agents are also safe.
What must you avoid? You must avoid ACE inhibitors, angiotensin receptor blockers, ARNIs, MRAs and SGLT2 inhibitors. There is specific teratogenic evidence with ACE inhibitors and angiotensin receptor blockers and limited data on the antiandrogenic effects of MRAs, and there just are not good data on SGLT2 inhibitors in humans. Based on all that, we have to pretend it’s 1989 for pregnant patients with HF. It is a matter of counseling the patient during pregnancy and letting them know that we prioritize the safety and health of the fetus, returning to the best therapy after delivery.
Breastfeeding is different. SGLT2 inhibitors are considered safe during breastfeeding and spironolactone is also safe. The NIH Drug and Lactation Database, LactMed, is a fantastic resource when you want to check which medications are safe for breastfeeding.
Healio: This review also highlights obstetric considerations around labor and delivery. What are those?
Kittleson: There is this idea that a cesarean section is safer because it is a controlled setting. A cesarean section is major surgery and it is gratifying to realize that, generally, the body knows what to do. Vaginal delivery is absolutely recommended for women with HF unless the obstetrician feels that cesarean section is necessary, because cesarean section is associated with increased fluid shift and higher risk for infection. Only consider a cesarean section if there is significant hemodynamic instability or the obstetrician has a need for it.
Healio: What can you tell us about the so-called fourth trimester, the period after delivery? What type of monitoring is needed for women with CVD?
Kittleson: We know that peripartum cardiomyopathy can present late in pregnancy or after delivery. It is a tricky time, that fourth trimester. We hear that phrase a lot with babies, but that phrase applies to mothers as well. Clinicians must be vigilant for the signs and symptoms of HF that can appear after delivery. If there are worrisome symptoms such as chest discomfort, shortness of breath or headaches, there could be post-pregnancy eclampsia. Patients need to know that they should not just write off what they may be feeling to being a new parent. Set up an appointment within 7 to 14 days with not just the obstetrician but the cardiologist to close the loop, ensure stability and resume or optimize GDMT depending on breastfeeding status.
Healio: What research is still needed?
Kittleson: There is so much we still do not know. For example, what is the role of bromocriptine for these patients? We know that bromocriptine may play a role in treatment of peripartum cardiomyopathy, according to what we have seen in small studies. The REBIRTH trial is assessing this in people with peripartum cardiomyopathy. However, this drug requires a big commitment because bromocriptine suppresses lactation, so it must be given to women who choose not to breastfeed.
We also must continue to study the origin of health care disparities we see, where the social determinants of health have a dramatic impact on outcomes. Is this biology? Is this disparity? Both? How do we untangle that so we can best treat it?
Also, not all high-risk patients are created equal. We need better registries so we can parse out, when counseling our patients, which of these factors we need to care about the most.
Reference:
For more information:
Michelle M. Kittleson, MD, PhD, can be reached at michelle.kittleson@cshs.org; Twitter: @mkittlesonmd.
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