Cardiac disease in pregnancy and drug therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
ACE inhibitors, Angiotensin receptor blockers (ARBss), aldosterone antagonists and warfarin should be avoided in pregnancy.
Contraindicated Drugs
- ACE inhibitors can cause morbidity in 30% of fetuses after 14 weeks due to renal tubular dysplasia, neonatal renal failure, oligohydroamnios, reduced cranial oosification and intrauterine growth retardation (IUGR)
- Angiotensin receptor blockers (ARBss). These agents are safe during lactation though.
- Aldosterone antagonists cause antiandrogenic effects in the first trimester and should be avoided.
- Warfarin is teratogenic
Drugs to be Avoided
- Atenolol
- Carvedilol
- The efficacy and safety of thrombolytics is mostly untested:
- Greatest experience in massive pulmonary embolism
- Streptokinase does not cross placental membrane in animals, but Ab found in neonatal spinal cord fluid
- Urokinase not teratogenic in mice/rats
- Risk for maternal hemorrhage (1 case of placental abruption reported); increased risk when given at time of delivery
- Delivery best delayed at least 2-3 weeks
Acceptable Drugs
- ASA - low doses should be used. Complications include an increased risk of abruptio placenta
- Beta-1 selective Beta-blockers like lopressor, metoprolol.
- Calcium channel blockers are often administered during the second and third trimesters of pregnancy to manage blood presure. However, during the first trimester during organogenesis, there may be a risk for teratogenicity based upon frog embryo studies, and CCBs are classified as pregnancy category C.
- Digoxin affects the fetus as well
- Diuretics can reduce placental perfusion and should be used sparingly
- Hydralazine
- Magnesium
- Morphine sulfate
- Nitrates – use low dose to prevent fetal distress