Table 1.
Safety of medications commonly used for the treatment of heart failure in pregnant and lactating women
| Medication class | Safe during pregnancy? | Safe while breastfeeding? | Comments |
|---|---|---|---|
| Beta blockers [45, 47–50] | |||
| – Metoprolol | Yes | Yes | Higher doses of beta blockers are associated with low fetal birth weight and hypoglycemia |
| – Bisoprolol | Yes | Yes | |
| – Carvedilol | Unknown | Unknown | |
| – Atenolol | No | No | |
| ACEi/ARB/ARNi [46, 51] | No | Captopril, benazepril, and enalapril considered safe | Teratogenic, with risks for oligohydramnios and skeletal, cranial, and fetal renal malformations |
| MR antagonists [5, 46, 52] | |||
| – Spironolactone | No | Yes | – Spironolactone is associated with antiandrogenic effects on fetus |
| – Eplerenone | Yes | Yes | – Eplerenone is associated with post-implantation losses at the highest administered doses in rabbits |
| SGLT2i [45, 53] | |||
| – Dapagliflozin | No | No | Insufficient data for pregnant or breastfeeding humans; renal harm noted in fetuses of rats |
| – Empagliflozin | No | No | |
| Loop diuretics [45, 46] | Yes | Yes, but can suppress lactation at high doses | More data with furosemide than with torsemide, bumetanide, and metolazone. Can be associated with oligohydramnios; close monitoring is warranted |
| Digoxin [46, 55, 56] | Yes | Yes | No adverse effects on the mother or fetus have been observed [72]. Digoxin intoxication has, however, been associated with miscarriage and fetal death [80, 81], so periodic drug monitoring is encouraged, especially given the altered pharmacokinetics with physiologic pregnancy changes |
| HCN channel blocker [97, 98] | |||
| – Ivabradine | No | No | Ivabradine is associated with embryonic bradycardia, hypoxia, malformations, and death in animal studies |
| sGC stimulator [99] | |||
| – Vericiguat | No | No | Vericiguat is associated with fetal harm in animal studies. No data on excretion in breastmilk |
| Inotropes [8, 45, 68, 69] | Used similarly in non-pregnant patients. Some suggestion of increased harm with beta-agonists in severe PPCM | ||
| – Dopamine | Yes | Yes | |
| – Dobutamine | Yes | Yes | |
| – Milrinone | Yes | Yes | |
| – Levosimendan | Yes | Yes | |
| Vasodilators [71, 72] | Nitroglycerin preferred over nitroprusside due to toxic fetal cyanide levels with latter | ||
| – Nitrates | Yes (except nitroprusside) | Yes | |
| – Calcium channel blockers | Yes | Yes | |
| – Hydralazine | Yes | Yes | |
| – Methyldopa | Yes | Yes | |
| Anticoagulants [5, 46, 57–59, 61–64, 100] | |||
| – VKA | Only at low doses in high risk scenarios | Yes | VKAs only to be considered for mechanical valves and LVADs and at doses of less than 5 mg/day |
| – LMWH | Yes | Yes | Close monitoring of factor Xa levels for LMWH |
| – DOACs | No | No | Limited data on DOAC use in pregnancy |
| Immunosuppressive agents [89] | |||
| – Corticosteroids | Yes | Yes | Cleft palate at high steroid doses |
| – Calcineurin inhibitors | Yes | Yes | Close monitoring and dose adjustments of calcineurin inhibitors needed in pregnancy |
| – mTOR inhibitors | Insufficient data | Insufficient data | Evaluate mTOR use on a case-by-case basis and discontinue use 6–12 weeks before conception if able |
| – Mycophenolate | No | No | Mycophenolate is teratogenic; associated with a high rate of spontaneous abortions and congenital malformations |
| – Azathioprine | Yes | Yes | Azathioprine with no evidence of teratogenic effects |
ACEi angiotensin-converting enzyme inhibitor, ARB angiotensin receptor blocker, ARNi angiotensin-receptor neprilysin inhibitor, MR mineralocorticoid receptor, SGLT2i sodium glucose cotransporter 2 inhibitor, HCN hyperpolarization-activated cyclic nucleotide-gated, sGC soluble guanylyl cyclase, VKA vitamin K antagonist, LMWH low molecular weight heparin, LVAD left ventricular assist device, DOAC direct oral anticoagulant, mTOR mammalian target of rapamycin, PPCM peripartum cardiomyopathy