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......................................... are sensitive to the toxic effects of beta-adrenergic agonists, which should be avoided whenever possible. Levosimendan may be the preferred inotrope.279,291,292

8.3.1.2 Acute/subacute heart failure Patients with symptoms and signs of acute HF should be evaluated according to acute HF Guidelines.289 Differential diagnoses include uncomplicated pregnancy, pulmonary oedema (pre-eclampsia/ eclampsia), PE, pneumonia, and MI, all of which should be diagnosed or excluded using standard algorithms. Management goals are similar to non-pregnant acute HF, while avoiding foetotoxic agents (ACE inhibitors, ARB, ARNI, MRA, and atenolol). HF with pulmonary congestion is treated with loop diuretics and thiazides if required; however, diuretics should be avoided in the absence of pulmonary congestion, due to the potential reduction in placental blood flow.290 Hydralazine and nitrates appear safe in pregnancy, although with less evidence for benefit than ACE inhibitors, and should only be used in the presence of hypertension, severe LV dysfunction, and/or evidence of congestion in decompensated HF. Beta-blockers should be initiated cautiously and gradually uptitrated to the maximum tolerated dose266,286 (details in section 12). High resting heart rate is a predictor of adverse outcome in PPCM, and treatment with ivabradine may be useful if the patient is not pregnant or breastfeeding.283,293

Relapse of PPCM has been observed after rapid tapering of HF therapies, and therefore treatment should continue for at least 6 months after full recovery of LV function followed by gradual tapering.264

Figure 6 Management of acute heart failure during/after pregnancy (modified from Bauersachs et al.280). aDiuretics have to be used with caution due to potential reduction in placental blood flow. ACE-I = angiotensin-converting enzyme inhibitor; AHF = acute heart failure; ARB = angiotensin receptor blocker; ECG = electrocardiogram; HF = heart failure; HR = heart rate; LVEF = left ventricular ejection fraction; MCS = mechanical circulatory support; MR = mineralocorticoid receptor; NIV = non-invasive ventilation; PDA = Peridural analgesia; PPCM = peripartum cardiomyopathy; RR = respiratory rate; SBP = systolic blood pressure; ScvO2 = central venous oxygen saturation; SpO2 = peripheral oxygen saturation; WCD = wearable cardioverter-defibrillator. Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026