ACC-2017 Pregnancy - CHD

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Template:Pregnancy -CHD - 2017 Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]

Management of Pregnancy in Patients With Complex Congenital heart Disease

Modified Who Classification of Maternal Cardiovascular Risk

Who Pregnancy Risk Category Risk Description Maternal Risk Factors
I No detectable increase in maternal mortality and no/mild increase in morbidity risk Uncomplicated small/mild pulmonary stenosis, PDA, mitral valve prolapse;

Successfully repaired simple lesions (ASD, VSD, PDA, anomalous pulmonary venous drainage); Atrial or ventricular ectopic beats, isolated

II Small increase in maternal mortality and moderate increase in morbidity risk If otherwise well and uncomplicated: Unoperated ASD, VSD;

Repaired TOF;

Most arrhythmias

II–III Moderate increase in maternal mortality morbidity risk Mild LV impairment;

Hypertrophic cardiomyopathy;

Native or tissue valvular disease (not considered risk category I or IV);

Marfan syndrome without aortic dilation;

Aortic dilation <45 mm in bicuspid aortic valve aortopathy;

Repaired coarctation

IV Extremely high maternal mortality or severe morbidity risk. Pregnancy is contraindicated. In the event of pregnancy, termination should be discussed. If pregnancy continues, care should follow class III recommendations. Pulmonary arterial hypertension (of any cause);

Severe systemic ventricular dysfunction (LV ejection fraction <30%, NYHA class III-IV);

Previous peripartum cardiomyopathy with any residual impairment of LV function;

Severe mitral stenosis, severe symptomatic aortic stenosis;

Aortic dilation >45 mm in Marfan syndrome;

Aortic dilation >50 mm in bicuspid aortic valve aortopathy;

Native severe coarctation

AS indicates aortic stenosis; ASD, atrial septal defect; CHD, congenital heart disease; LV, left ventricular; NYHA, New York Heart Association; PDA, patent ductus arteriosus; RV, right ventricle; TOF, tetralogy of Fallot; VSD, ventricular septal defect; and WHO, World Health Organisation.

Medications During Pregnancy

Common Examples FDA Pregnancy Category Teratogenic risks (First Trimester) Other Pregnancy Concerns (Second and Third Trimesters) Suggested Evaluation Lactation Notes
Antihypertensives
β-Blockers Metoprolol Propranolol Carvedilol Atenolol C

C C

D

None reported Possible association with fetal growth restriction in second and third trimesters (atenolol, propranolol), neonatal bradycardia (esmolol, nadolol) Consider serial fetal sonography to assess interval fetal growth in second and third trimesters Except for atenolol, probably safe
Combined α-/β- blockers Labetalol C None reported No Yes
Calcium channel blockers Nifedipine Verapamil Diltiazem C None reported Caution if used in combination with magnesium sulfate Yes
ACE inhibitors Captopril Enalapril Lisinopril C ( first trimester)

D (second and third trimesters)

Fetal renal dysplasia, oligohydramnios, growth restriction, and intrauterine demise reported in second and third trimesters Consider fetal echocardiography with rst trimester exposure, serial sonography to assess interval fetal growth and amniotic fluid volume in second and third trimesters Yes (captopril and enalapril) Unknown (lisinopril) Avoid if possible during pregnancy
α2- Adrenergic agonists Methyldopa Clonidine B

C

None reported Induction of positive indirect Coombs testing (methyldopa), rare neonatal hypertension (clonidine) Yes (methyldopa) Probably safe (clonidine)
Vasodilators Hydralazine Epoprostenol Nitroprusside Nitroglycerin Isosorbide dinitrate Sildenafil C

B B

None reported Possible transient fetal bradycardia (nitroprusside) Yes (hydralazine) Probably safe (nitroglycerin) Unknown (epoprostenol, nitroprusside, isosorbide dinitrate, sildenafil)
Diuretics
Thiazide diuretics Hydrochlorothiazide B None reported Possible increased risk of neonatal hypoglycemia and thrombocytopenia Consider neonatal blood count and electrolyte evaluation Yes (AAP) No (WHO) Maintenance therapy permissible, but therapy not usually started during pregnancy
Loop of Henle diuretics Furosemide C None reported Possible association with neonatal PDA and sensorineural hearing loss Maternal electrolyte monitoring No
Potassium- sparing diuretics Spironolactone (not recommended) C None reported Yes (probably safe; (not recommended)
Anticoagulants
Heparin (including LMWHs) Heparin Enoxaparin Dalteparin C None reported Possible maternal osteoporosis, heparin-induced thrombocytopenia, and bleeding Maternal platelet and coagulation status monitoring (as appropriate) Yes
Vitamin K antagonists Warfarin X Fetal warfarin syndrome (craniofacial and skeletal anomalies) with exposure in weeks 6–9; fetal intracranial hemorrhage in second and third trimesters Comprehensive fetal sonography at 18–20 wk of gestation Yes Teratogenicity appears to be related to doses >5 mg daily
Antiplatelet agents Aspirin (full dose) Clopidogrel D (third trimester)

B

None reported Premature closure of fetal ductus arteriosus at ≥32 wk of gestation Empirical recommendation to discontinue clopidogrel 7 d in advance of anticipated delivery Unknown (AAP) No (WHO) Low-dose aspirin (≤100 mg/d) does not appear to have deleterious effects
Direct thrombin inhibitors Argatroban B None reported Unknown
Indirect factor Xa inhibitors Fondaparinux B None reported Possible neonatal factor Xa inhibition Unknown
Direct factor Xa inhibitors Rivaroxaban C None reported Theoretical risk of maternal hemorrhage Unknown
Fibrinolytics Streptokinase C None reported Unknown
Inotropic/vasopressors
Cardiac glycosides Digoxin Digitalis C None reported Yes
Adrenergic agents Epinephrine Norepinephrine Phenylephrine Dopamine Isoproterenol C Possible association with gastroschisis or hemifacial microsomia (phenylephrine) Probably safe (dopamine) Unknown (epinephrine, norepinephrine, phenylephrine, isoproterenol)
Antiarrhythmics
β-Blockers Metoprolol Propranolol Carvedilol Atenolol C

C C

D

None reported Association with fetal growth restriction in second and third trimesters (atenolol, propranolol), neonatal bradycardia (esmolol, nadolol) Consider serial fetal sonography to assess interval fetal growth in second and third trimesters Except for atenolol, probably safe
Class 1A Quinidine Procainamide C

C

None reported Yes
Class 1C Flecainide C None reported Yes
Class III Sotalol Amiodarone B

D

None reported Thyroid dysfunction No No WHO)/ (AAP Yes)
Purine nucleosides Adenosine C None reported Unknown
AAP indicates American Academy of Pediatrics; ACE, angiotensin-converting enzyme; FDA, US Food and Drug Administration; LMWH, low-molecular- weight heparin; PDA, patent ductus arteriosus; and WHO, World Health Organisation.