ACC-2017 Pregnancy - CHD
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. | |||||||