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8.2.2.3 Timing and mode of delivery

The timing and mode of delivery should be personalized according to the type of cardiomyopathy, ventricular function, NYHA class, arrhythmic risk, and thrombo-embolic risk. Vaginal delivery is associated with less blood loss and lower risk of infection, venous thrombosis, and embolism than caesarean section and should be advised for most women. Caesarean section should be considered for obstetric indications, patients with severe outflow tract obstruction, or in cases of severe acute/intractable heart failure, or in cases at high risk of threatening arrhythmia and for patients presenting in labour on oral anticoagulants.1130 During delivery, patients with cardiomyopathy should be circulatory and heart rhythm monitored on an individualized basis.

8.2.2.4 Post-partum

The post-partum period is associated with significant haemodynamic changes and fluid shifts, particularly in the first 24–48 h after delivery, which may precipitate heart failure. Haemodynamic monitoring should therefore be continued for at least 24–48 h in patients at risk. Most drugs enter the milk and could thus contraindicate breastfeeding (see Section 8.2.2.5).

8.2.2.5 Pharmacological treatment: general aspects

Pharmacological treatment in pregnant women should be the same as in non-pregnant patients, with an avoidance of drugs contraindicated in pregnancy, such as ACE-Is, ARBs, and renin inhibitors.1130 The first trimester is associated with the greatest teratogenic risk. Pharmacologic therapy is advised to begin as late as possible in pregnancy and at the lowest effective dose. Drug exposure later in pregnancy may confer adverse effects on foetal growth and development. It is recommended to check drug and safety data before initiation of a new drug in pregnancy; see Table 7 in the 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy.1130 From this list, antiarrhythmics can be summarized as follows: • Well tolerated: sotalol, oral verapamil. • While the benefits and risks should be evaluated in each case, the following drugs can often be continued if there is a clear indication for use during pregnancy: bisoprolol, carvedilol, digoxin, diltiazem (possible teratogenic effects), disopyramide (uterine contractions), flecainide, lidocaine, metoprolol, nadolol, propranolol, verapamil, quinidine. • Insufficient data: ivabradine, mexiletine, propafenone, vernakalant. • Contraindicated: amiodarone, atenolol, dronedarone, ACE-Is, ARBs, renin inhibitors, and spironolactone.1130

Ongoing beta-blocker treatment in cardiomyopathies should be continued during pregnancy, with close monitoring of foetal growth. After delivery, it is advised to heart rhythm monitor the infant for 48 h. The use of beta-blockers and anticoagulation during pregnancy is described in the 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy.1130 Vitamin K antagonist use in the first trimester results in embryopathy (limb defects, nasal hypoplasia) in 0.6–10% of cases.1133,1134 In contrast, unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) do not cross the placenta; therefore, substitution of VKA with UFH or LMWH in weeks 6–12 almost eliminates the risk of embryopathy. This risk is also dose dependent (0.45–0.9% with low-dose warfarin). Vaginal delivery while the mother is on VKAs is contraindicated because of the risk of foetal intracranial bleeding. Haemorrhagic complications in the mother occur with all regimens, but the incidence is lower with VKA than with LMWH/UFH throughout pregnancy.1130

VKA should be continued until pregnancy is achieved. Continuation of VKAs throughout pregnancy should be considered when the dose is low (see Table 7 in the 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy1130). The target international normalized ratio (INR) should be chosen according to current guidelines, with INR monitoring weekly or every 2 weeks. Self-monitoring of INR in suitable patients is recommended. Alternatively, depending on the indication, a switch to LMWH from weeks 6–12 under strict monitoring may be considered in patients with a low dose requirement. When a higher dose of VKAs is required, discontinuation of VKAs between weeks 6 and 12 and replacement with adjusted-dose i.v. UFH or LMWH twice daily with dose adjustment according to peak anti-Xa (for LMWH) levels should be considered. In case of delivery in anticoagulated women (not including mechanical valves) with a planned caesarean section, therapeutic LMWH dosing can be simply omitted for 24 h prior to surgery. If delivery has to be performed earlier, anti-Xa activity can guide the timing of the procedure. Antiarrhythmic therapy in pregnancy other than medication. Implantation of an ICD and catheter ablation should ideally be considered prior to pregnancy in patients with a high risk of ventricular arrhythmias to avoid implantations and interventions during pregnancy.1135 If an ICD is indicated in pregnancy, ICD implantation should be performed beyond 8 weeks of gestation with radiation protection1136 and the indication should be weighed against the limited experience available. In pregnant patients with existing ICD, routine ICD interrogation and advice are recommended prior to delivery.

8.2.2.6 Specific cardiomyopathies

Most women with HCM tolerate pregnancy well.1137 Complications during pregnancy most often occur in women who have symptoms, arrhythmias, or impaired LV function before pregnancy. Left ventricular outflow tract gradients may increase slightly during pregnancy and high gradients before pregnancy are associated with more complications.1137 Women should be assessed according to WHO risk class, indicating at trimester for low-risk patients (class II) and monthly or bi-monthly for higher-risk patients (class III). Therapeutic anticoagulation with LMWH or VKAs according to the stage of pregnancy is recommended for patients with AF. Cardioversion in pregnancy should be considered for poorly tolerated persistent AF. Hypovolaemia is poorly tolerated. Caesarean section should be considered in patients with severe LVOTO, pre-term labour while on oral anticoagulants, or severe heart failure.1130 Epidural and spinal anaesthesia must be applied cautiously, especially with severe LVOTO, due to potential hypovolaemia, and single-shot spinal anaesthesia should be avoided. Pregnancy in ARVC seems to be relatively tolerable, as shown in several studies, with no excess mortality and no clear negative long-term outcome.1138–1141 Previous VTs represent a WHO risk class III, indicating bi-monthly or monthly follow-up at an expert centre. Women with DCM are at risk of further deterioration of LV function in pregnancy. Data suggest that pregnancy might not be associated with long-term adverse disease progression or event-free survival in LMNA genotype-positive women.1142 Predictors of maternal mortality are NYHA class III/IV and EF <40%. Highly adverse risk factors include Downloaded from academic.oup.com/eurheartj/article/44/37/3503/7246608 by guest on 07 October 2026