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............................................................................................................................................................................. 8.3.2 Bromocriptine and peripartum cardiomyopathy Addition of bromocriptine to standard HF therapy may improve LV recovery and clinical outcome in women with acute severe PPCM.24,25,277,278,294 Bromocriptine (2.5 mg once daily) for at least 1 week may be considered in uncomplicated cases, whereas prolonged treatment (2.5 mg twice daily for 2 weeks, then 2.5 mg once daily for 6 weeks) may be considered in patients with EF <25% and/or cardiogenic shock. Bromocriptine treatment must always be accompanied by anticoagulation with heparin (LMWH or UFH), at least in prophylactic dosages.25,294,295 The essential therapies for patients with acute PPCM have been summarized under the BOARD label: Bromocriptine, Oral heart failure therapies, Anticoagulants, vasoRelaxing agents, and Diuretics.296

8.3.3 Devices and transplantation Given the high rate of improvement of LV function during optimal HF drug therapy, early implantation of an implantable cardioverterdefibrillator (ICD) in patients with newly diagnosed PPCM or DCM is not appropriate. A wearable cardioverter-defibrillator (WCD) may prevent sudden cardiac death (SCD) during the first 3–6 months after diagnosis, especially in patients with EF <35%, allowing protected recovery from severe LV impairment.279,297 In severe LV dysfunction during the 6–12 months following first presentation despite optimal medical therapy, implantation of an ICD and cardiac resynchronization therapy (for patients with left bundle branch block and QRS >130ms) are recommended.286,298 However, mortality reduction in those with non-ischaemic cardiomyopathy is uncertain.299 Cardiac transplantation is reserved for patients where mechanical circulatory support is not possible or desirable, or for patients who do not recover after 6–12 months. Patients with PPCM have higher rates of graft failure and death after heart transplantation.300

8.3.3.1 Pregnancy post-cardiac transplantation Despite successful pregnancies post-cardiac transplantation, data are limited. Multidisciplinary team management is required relating to the timing and management of pregnancy.301 Pre-conception counselling includes the risks of graft rejection and dysfunction, infection, and the teratogenicity of immunosuppressive agents. Some centres recommend human leucocyte antigen testing prior to conception. If the donated heart and father have the same human leucocyte antigen, and the recipient has donor-specific antigens, the risk of autograft rejection is high.302 PPCM recurrence rates in transplanted patients are unknown. However, as rejection risk in these patients is higher in the first year post-transplant and graft survival is shorter, many advise against pregnancy in such patients.303 Pregnancy should be avoided for at least 1 year posttransplantation, and discouraged in patients at high-risk of rejection and/or with poor baseline graft function before pregnancy.303–305 Besides graft rejection or dysfunction and infection, hypertension is the most common maternal complication. Additional increased risks include hyperemesis and thrombo-embolic disease.301 All immunosuppressive medications enter the foetal circulation, thus the management of immunosuppression in the pregnant post-transplant recipient is highly specialized.301 As all immunosuppressive agents are excreted into breast milk with unknown long-term effects, the International Society for Heart and Lung Transplantation currently recommends against breastfeeding.303 8.3.4 Anticoagulation Standard indications for anticoagulation in PPCM and DCM apply during and after pregnancy. The choice of anticoagulant agent depends upon the stage of pregnancy and patient preference (see section 12 and Table 7).9,306 In PPCM patients with very low EF, prophylactic anticoagulation should be considered.263

8.3.5 Delivery and breastfeeding Urgent delivery irrespective of gestation duration should be considered in women with advanced HF and haemodynamic instability despite treatment.279 Caesarean section is recommended with central neuraxial anaesthesia. To prevent abrupt pressure or volume changes, epidural anaesthesia might be the method of choice but should be carefully titrated, guided by an expert anaesthetic team.279,290 In stable congestive HF, vaginal delivery is preferred with spinal/epidural analgesia. In HF with reduced EF (HFrEF), breastfeeding is discouraged in more severe cases (e.g. NYHA III/IV). Stopping lactation reduces the high metabolic demand and enables early optimal HF treatment.24 For drug treatment during breastfeeding see section 12.

8.4 Hypertrophic cardiomyopathy

The true prevalence of HCM in different populations is a topic of debate, but a number of methodologically diverse studies in North America, Europe, Asia, and Africa have reported a prevalence of unexplained increase in LV thickness in the range of 0.02–0.23% in adults.65 The observed incidence of HCM in pregnancy is <1:1000.65,307 Women with HCM usually tolerate pregnancy well. In a recent meta-analysis, maternal mortality was 0.5%, and complication or worsening of symptoms occurred in 29% of cases. Foetal mortality by spontaneous abortion (15%), therapeutic abortion (5%), or stillbirth (2%) is comparable to the general population; however, the risk of premature birth is increased (26%).308,309 Risk is increased where women are symptomatic pre-pregnancy or exhibit a high-risk profile, including diastolic dysfunction, severe LV outflow tract obstruction, and arrhythmia.310,311 Medication in the pre-pregnancy period, and a CARPREG or ZAHARA score >_1, are risk factors for pregnancy/ post-partum cardiac events.312 Symptoms are typical for HF with pulmonary congestion and echocardiography is usually diagnostic.

8.4.1 Management Women in WHO class II should be assessed each trimester, and those in class III assessed monthly or bimonthly.9 Beta-blockers should be continued if they are already being taken (see section 12). They should be started when new symptoms occur, for rate control in AF, and to suppress ventricular arrhythmias, with verapamil as second choices when beta-blockers are not tolerated (with foetal monitoring for AV block).65,313 Cardioversion should be considered for poorly tolerated persistent AF.314 Therapeutic anticoagulation is recommended for those with paroxysmal or persistent arrhythmias. Hypovolaemia is poorly tolerated. Patients with a past history or family history of sudden death need close surveillance with prompt investigation if they develop symptoms of palpitations or presyncope. When indicated, a device should be implanted 315,316 Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026