Cardiovascular Disease in Pregnancy

Approach

1. Risk class: mWHO III (systemic right ventricle with preserved or slightly reduced function); The risk of maternal mortality or severe morbidity is significantly increased. Explain that pregnancy is not absolutely contraindicated, but complications are common and intensive monitoring is required during antenatal, delivery and postpartum periods.
2. Follow up from pre-pregnancy to puerperium in a specialist center with an experienced team and a Pregnancy Heart Team. Perform cardiology follow-up usually every 1-2 months.
3. Discuss the risk of premature failure of the systemic right ventricle; A more rapid decline in right ventricular systolic function has been reported in pregnancy after atrial switch. Monitor functional status and cyanosis as the most reliable risk markers; Entering pregnancy with NYHA III–IV is associated with a severe course. Consider the systemic right ventricle 'at risk' during the puerperium and monitor closely for failure. Plan extended monitoring and early follow-up for 48–72 hours after birth.
4. Record baseline ECG, ECHO, oxygen saturation and BNP/NT-proBNP; additionally use the ZAHARA score in risk estimation.
5. Treat persistent, symptomatic or decompensating arrhythmia without delay by evaluating its type and hemodynamic effect.
6. Monitor fetal growth; Plan delivery at a center with neonatal intensive care facilities. Discuss the risk of recurrence of congenital heart disease in the child (including the possible type of lesion if a first-degree relative is affected) and recommend fetal echocardiography at 18–22 weeks.
7. Determine mode of delivery according to obstetric indication; Perform cesarean section only for obstetric indication, not routinely. Create a birth plan in advance and share it with the entire team; Perform prenatal obstetric anesthesia evaluation and provide continuous telemetry during labor.
8. Initiate contraception counseling before need arises; The intrauterine device is an excellent option.

Treatment

• If there is tachyarrhythmia requiring rate control during puerperium — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• If there are signs of systemic right ventricular failure or ventricular dysfunction during puerperium, for afterload reduction by expert cardiology decision — Enalapril: 2.5 mg twice a day is started; The target is 10–20 mg twice a day, doubling the dose every 1–2 weeks.
• If there is congestion or fluid overload in the puerperium — Furosemide (oral): 20–40 mg once a day is started; If the response is insufficient, the single dose is adjusted by doubling instead of giving the same dose more frequently; The new dose is given no earlier than 6–8 hours after the previous dose; usual dose 40–240 mg per day; Maximum total daily dose of 600 mg (up to 1000 mg in severe renal impairment).

Note

• If pregnancy is planned, discontinue ACE inhibitor and ARB before pregnancy or switch to pregnancy-compatible alternatives; Assess maternal stability with changed therapy. If the first application is during pregnancy, do not delay medication adjustment. Discontinue the ACE inhibitor at the beginning of the first trimester to prevent fetal renal complications.
• Evaluate the safety of each medication separately during breastfeeding in the breastfeeding patient before discharge.
• Do not automatically start aggressive pharmacological treatment for isolated benign premature beats.
• Do not routinely start metoprolol, enalapril or furosemide solely because a patient is postpartum when function is preserved and there are no symptoms or congestion.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Enalapril: Contraindicated in pregnancy; Can be used during breastfeeding. If serum sodium is <130 mEq/L or serum creatinine is >1.6 mg/dL, start with 2.5 mg once daily under close supervision; The dose is increased every 4 days at the earliest unless there is severe hypotension or significant deterioration of renal function.
• Furosemide (oral): No breastfeeding difficulties have been reported with the low dose (20 mg/day) in breastfeeding.
• Furosemide (oral): Use with caution during pregnancy as excessive diuresis may reduce uterine blood flow and placental perfusion.

Approach

1. Risk class: mWHO IV (NYHA III–IV, systemic right ventricle with more than mild ventricular dysfunction, more than moderate tricuspid regurgitation, or treated heart failure); The risk of maternal mortality or severe morbidity is extremely high, pregnancy is contraindicated.
2. Record NYHA functional class, rhythm, and history of previous cardiac events at initial evaluation; Evaluate ventricular and valve function, pulmonary pressure with ECG and ECHO; Document baseline oxygen saturation.
3. Recommend avoiding pregnancy if pregnancy is planned; Discuss maternal risk, fetal outcomes, uncertainty in the evidence, and reproductive alternatives individually. Document in the record that pregnancy is contraindicated, lesion-specific rationale, and the patient's understanding and preferences.
4. Avoid estrogen-containing combined hormonal contraception; choose long-acting methods such as intrauterine device or progestin implant; In selection, consider anticoagulation, bleeding profile, risk of infection, and vasovagal response during insertion. If permanent contraception is considered, make the decision without pressure, by mutual consent; Assess procedure and anesthesia risks in advance.
5. If pregnancy has occurred, refer urgently to the specialist Pregnancy Heart Team; In early counseling, discuss the risk to the mother, the option of continuing in a specialist center and, if legally and ethically appropriate, the option of terminating the pregnancy. If pregnancy persists, centralize care at a tertiary or quaternary center with advanced cardiac, obstetric, anesthesia, intensive care, and neonatal expertise.
6. If pregnancy persists, closely monitor the systemic right ventricle with an experienced team; Consider the patient 'at risk' during the puerperium and continue monitoring for insufficiency. Plan extended monitoring and early follow-up for 48–72 hours after birth. Treat chronic, symptomatic or decompensating arrhythmia without delay by evaluating its type and hemodynamic effect.
7. Monitor fetal growth; Plan delivery at a center with neonatal intensive care facilities. If pregnancy continues, discuss the risk of recurrence of congenital heart disease in the child and recommend fetal echocardiography at 18–22 weeks.
8. Prefer vaginal birth; Perform cesarean section in obstetric indication or acute refractory heart failure. Create a birth plan in advance and share it with the entire team; Perform prenatal obstetric anesthesia evaluation and provide continuous telemetry during labor.

Treatment

• If there is tachyarrhythmia requiring rate control during puerperium — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• If there are signs of systemic right ventricular failure or ventricular dysfunction during puerperium, for afterload reduction by expert cardiology decision — Enalapril: 2.5 mg twice a day is started; The target is 10–20 mg twice a day, doubling the dose every 1–2 weeks.
• If there is congestion or fluid overload in the puerperium — Furosemide (oral): 20–40 mg once a day is started; If the response is insufficient, the single dose is adjusted by doubling instead of giving the same dose more frequently; The new dose is given no earlier than 6–8 hours after the previous dose; usual dose 40–240 mg per day; Maximum total daily dose of 600 mg (up to 1000 mg in severe renal impairment).

Note

• If pregnancy is planned, discontinue ACE inhibitor and ARB before pregnancy or switch to pregnancy-compatible alternatives; Assess maternal stability with changed therapy. If the first application is during pregnancy, do not delay medication adjustment. Discontinue the ACE inhibitor at the beginning of the first trimester to prevent fetal renal complications.
• Evaluate the safety of each medication separately during breastfeeding in the breastfeeding patient before discharge.
• Do not automatically start aggressive pharmacological treatment for isolated benign premature beats.
• Do not routinely start metoprolol, enalapril or furosemide solely because a patient is postpartum when function is preserved and there are no symptoms or congestion.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Enalapril: Contraindicated in pregnancy; Can be used during breastfeeding. If serum sodium is <130 mEq/L or serum creatinine is >1.6 mg/dL, start with 2.5 mg once daily under close supervision; The dose is increased every 4 days at the earliest unless there is severe hypotension or significant deterioration of renal function.
• Furosemide (oral): No breastfeeding difficulties have been reported with the low dose (20 mg/day) in breastfeeding.
• Furosemide (oral): Use with caution during pregnancy as excessive diuresis may reduce uterine blood flow and placental perfusion.

Approach

1. Apply the mWHO IV approach if LVEF < 30% or NYHA III–IV heart failure, regardless of the severity of the valve lesion: recommend avoiding pregnancy; If pregnancy has occurred, discuss the option of terminating it if it is legally and ethically appropriate.
2. Moderate mitral stenosis is mWHO III; Calculate individual risk with CARPREG II.
3. Identify before pregnancy and evaluate with the Pregnancy Heart Team; Perform the evaluation with a cardiologist experienced in pregnancy and valve disease: detailed history, previous valve interventions, symptom status, physical examination, ECG, ECHO and functional evaluation.
4. Determine the severity of stenosis, ventricular function, and pulmonary hypertension by ECHO; Objectively evaluate functional capacity with exercise testing.
5. Consider preconception intervention or advice to avoid pregnancy in symptomatic and selected asymptomatic patients; If intervention is necessary, complete it before pregnancy.
6. Explain to the woman referred for intervention the risks and benefits of each option: if replacement is required, weigh the fetal risks of thromboembolism and anticoagulation in pregnancy with a mechanical valve, limited durability of the bioprosthesis, and the need for reintervention; If appropriate, choose repair over replacement.
7. Advise women with moderate valve disease remaining after repair not to delay pregnancy.
8. For congenital stenosis, address the fetal recurrence risk during counseling and plan fetal echocardiography at 18–22 weeks of pregnancy.
9. Provide effective contraception until intervention or optimization is completed; Choose long-acting reversible methods.

Treatment

• If the mitral valve area is < 1.5 cm², perform valve intervention before pregnancy, even if there are no symptoms; The first option is percutaneous mitral balloon commissurotomy in appropriate anatomy.

Note

• Stenosis gradients increase during pregnancy; Interpret ECHO findings accordingly.
• Review current medications; Discontinue or change teratogenic or fetotoxic heart medications such as ACE inhibitors and ARBs.

Approach

1. Apply the mWHO IV approach if LVEF < 30% or NYHA III–IV heart failure, regardless of the severity of the valve lesion: recommend avoiding pregnancy; If pregnancy has occurred, discuss the option of terminating it if it is legally and ethically appropriate.
2. Moderate mitral stenosis is mWHO III; Calculate individual risk with CARPREG II.
3. Manage at a specialist center with a Pregnancy Heart Team; Have your cardiology check-up usually every 1-2 months and create your birth plan early.
4. Perform a comprehensive risk assessment at the first antenatal visit in a woman who has not received pre-pregnancy counseling, with detailed history, previous valve interventions, symptom status, physical examination, ECG, ECHO and functional evaluation; Monitor for atrial fibrillation and pulmonary edema during pregnancy.
5. Consider anticoagulation in cases of significant stenosis, spontaneous echo contrast in the left atrium, left atrial volume index > 60 mL/m², or heart failure.
6. Monitor fetal growth; in congenital stenosis, address the fetal recurrence risk during counseling and plan fetal echocardiography at 18–22 weeks.
7. Plan the birth at a reference center with neonatal intensive care facilities; Prepare the birth plan in advance and distribute it to the entire team, perform prenatal obstetric anesthesia evaluation and apply continuous telemetry during labor.
8. Plan vaginal delivery with appropriate analgesia, minimizing Valsalva.
9. Consider monitoring women at highest risk for heart failure or who develop heart failure during pregnancy or birth in intensive (cardiac) care for hemodynamic monitoring for the first 24–48 hours postpartum.
10. Determine frequency of postpartum check-ups based on lesion and symptoms (hemodynamic changes of pregnancy may take up to 6 months to resolve); Choose long-acting reversible methods of contraception (intrauterine device, progestin implant) and individualize the choice according to the lesion, anticoagulation status and bleeding profile.

Treatment

• In symptomatic mitral stenosis or pulmonary hypertension, restrict physical activity and initiate beta blockers — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• If congestive symptoms persist despite beta blocker — Furosemide (oral): 20–40 mg once daily is started; If the response is insufficient, the single dose is adjusted by doubling instead of giving the same dose more frequently; The new dose is given no earlier than 6–8 hours after the previous dose; usual dose 40–240 mg per day; Maximum total daily dose of 600 mg (up to 1000 mg in severe renal impairment).
• In pulmonary edema — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in patients who have not previously used diuretics; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• In the presence of atrial fibrillation, left atrial thrombus, or previous embolism, administer full therapeutic dose anticoagulation: usually LMWH (enoxaparin based on body weight, usually 1 mg/kg SC every 12 hours) or VKA.
• If NYHA III–IV symptoms or systolic pulmonary artery pressure > 50 mmHg persist despite beta blockers and diuretics, perform percutaneous mitral balloon commissurotomy in appropriate anatomy (preferably after the 20th week).
• Only perform open valve surgery if the mother's life is in danger and other treatment methods cannot be applied or have failed.
• If cardiopulmonary bypass is mandatory, apply high flow (2.5 L/min/m²) and mean arterial pressure greater than 70 mmHg.
• If cesarean delivery is to be performed — Cefazolin: 2 g IV as a single dose for weight under 120 kg, or 3 g IV for 120 kg and above, within 60 minutes before skin incision; repeat the dose if the procedure is still ongoing 4 hours after the first dose or if blood loss exceeds 1500 mL; for cesarean delivery performed during labor or after membrane rupture, add azithromycin 500 mg as a single IV infusion in 250 mL of compatible fluid over 1 hour (do not administer as an IV bolus or IM); in severe beta-lactam allergy, administer clindamycin 900 mg IV + gentamicin 5 mg/kg IV single dose instead of cefazolin (if actual weight is more than 20% above ideal weight, dosing weight = ideal weight + 0.4 × (actual weight − ideal weight)); if in labor or membranes are ruptured, add azithromycin in the same manner.

Note

• Avoid atenolol as a beta blocker.
• Consider fetal radiation exposure and risk of maternal and fetal complications during valve intervention during pregnancy; Rewarming after deep hypothermia in cardiopulmonary bypass may trigger preterm labor.
• Left atrial thrombus or more than mild mitral regurgitation is a contraindication for percutaneous balloon commissurotomy.
• Stenosis gradients increase during pregnancy; Interpret ECHO findings accordingly.
• Review current medications; Discontinue or change teratogenic or fetotoxic cardiac medications during pregnancy, such as ACE inhibitors and ARBs; Captopril, enalapril and benazepril can be used in breastfeeding after birth, ARB is not recommended.
• Caesarean section prophylaxis also protects against endocarditis; Routine antibiotic prophylaxis is not required for vaginal delivery; some clinicians give it to women with previous infective endocarditis.
• Review the breastfeeding safety of each medication in the breastfeeding woman prior to discharge.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Furosemide (oral): No breastfeeding difficulties have been reported with the low dose (20 mg/day) in breastfeeding.
• Furosemide (oral): Use with caution during pregnancy as excessive diuresis may reduce uterine blood flow and placental perfusion.
• Furosemide (IV): Since excessive diuresis during pregnancy may reduce uterine blood flow and placental perfusion, it is used with caution and the dose is titrated only in cases of pulmonary congestion or volume overload.

Approach

1. Severe mitral stenosis is mWHO IV; Pregnancy is not recommended. Write in the record that pregnancy is contraindicated, the lesion-specific rationale, and the patient's understanding and preferences.
2. Identify before pregnancy and evaluate with the Pregnancy Heart Team; Perform the evaluation with a cardiologist experienced in pregnancy and valve disease: detailed history, previous valve interventions, symptom status, physical examination, ECG, ECHO and functional evaluation.
3. Determine the severity of stenosis, valve morphology, ventricular function and pulmonary hypertension by ECHO.
4. Explain to the woman referred for intervention the risks and benefits of each option: if replacement is required, weigh the fetal risks of thromboembolism and anticoagulation in pregnancy with a mechanical valve, limited durability of the bioprosthesis, and the need for reintervention; If appropriate, choose repair over replacement.
5. Advise women with moderate valve disease remaining after repair not to delay pregnancy.
6. For congenital stenosis, address the fetal recurrence risk during counseling and plan fetal echocardiography at 18–22 weeks of pregnancy.
7. Provide effective contraception until intervention or optimization is completed; Choose long-acting reversible methods.

Treatment

• If the valve morphology is suitable, perform percutaneous mitral balloon valvotomy before pregnancy.
• If the morphology is not suitable for balloon valvotomy, complete the necessary valve intervention before pregnancy.

Note

• Review current medications; Discontinue or change teratogenic or fetotoxic heart medications such as ACE inhibitors and ARBs.

Approach

1. Severe mitral stenosis is mWHO IV; If pregnancy has occurred, discuss the maternal risk, continuation in a specialist center, and the option of termination if legally and ethically appropriate.
2. If pregnancy persists, concentrate care at a tertiary or quaternary center with advanced cardiac, obstetric, anesthesia, intensive care and neonatal facilities.
3. Perform a comprehensive risk assessment at the first antenatal visit in a woman who has not received pre-pregnancy counseling, with detailed history, previous valve interventions, symptom status, physical examination, ECG, ECHO and functional evaluation; Monitor for atrial fibrillation and pulmonary edema during pregnancy.
4. Consider anticoagulation in cases of significant stenosis, spontaneous echo contrast in the left atrium, left atrial volume index > 60 mL/m², or heart failure.
5. Monitor fetal growth; in congenital stenosis, address the fetal recurrence risk during counseling and plan fetal echocardiography at 18–22 weeks.
6. Plan the birth at a reference center with neonatal intensive care facilities; Prepare the birth plan in advance and distribute it to the entire team, perform prenatal obstetric anesthesia evaluation and apply continuous telemetry during labor.
7. Vaginal birth is the general preference; Cesarean section is preferred in severe mitral stenosis and resistant heart failure.
8. Consider monitoring women at highest risk for heart failure or who develop heart failure during pregnancy or birth in intensive (cardiac) care for hemodynamic monitoring for the first 24–48 hours postpartum.
9. Determine the frequency of postpartum check-ups according to the lesion and symptoms; It may take up to 6 months for the hemodynamic changes of pregnancy to resolve.
10. Prefer long-acting reversible methods of contraception (intrauterine device, progestin implant); Individualize selection based on lesion, anticoagulation status, and bleeding profile.

Treatment

• In symptomatic mitral stenosis or pulmonary hypertension, restrict physical activity and initiate beta blockers — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• If congestive symptoms persist despite beta blocker — Furosemide (oral): 20–40 mg once daily is started; If the response is insufficient, the single dose is adjusted by doubling instead of giving the same dose more frequently; The new dose is given no earlier than 6–8 hours after the previous dose; usual dose 40–240 mg per day; Maximum total daily dose of 600 mg (up to 1000 mg in severe renal impairment).
• In pulmonary edema — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in patients who have not previously used diuretics; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• In the presence of atrial fibrillation, left atrial thrombus, or previous embolism, administer full therapeutic dose anticoagulation: usually LMWH (enoxaparin based on body weight, usually 1 mg/kg SC every 12 hours) or VKA.
• If NYHA III–IV symptoms or systolic pulmonary artery pressure > 50 mmHg persist despite beta blockers and diuretics, perform percutaneous mitral balloon commissurotomy in appropriate anatomy (preferably after the 20th week).
• Only perform open valve surgery if the mother's life is in danger and other treatment methods cannot be applied or have failed.
• If cardiopulmonary bypass is mandatory, apply high flow (2.5 L/min/m²) and mean arterial pressure greater than 70 mmHg.
• If cesarean delivery is to be performed — Cefazolin: 2 g IV as a single dose for weight under 120 kg, or 3 g IV for 120 kg and above, within 60 minutes before skin incision; repeat the dose if the procedure is still ongoing 4 hours after the first dose or if blood loss exceeds 1500 mL; for cesarean delivery performed during labor or after membrane rupture, add azithromycin 500 mg as a single IV infusion in 250 mL of compatible fluid over 1 hour (do not administer as an IV bolus or IM); in severe beta-lactam allergy, administer clindamycin 900 mg IV + gentamicin 5 mg/kg IV single dose instead of cefazolin (if actual weight is more than 20% above ideal weight, dosing weight = ideal weight + 0.4 × (actual weight − ideal weight)); if in labor or membranes are ruptured, add azithromycin in the same manner.

Note

• Avoid atenolol as a beta blocker.
• Consider fetal radiation exposure and risk of maternal and fetal complications during valve intervention during pregnancy; Rewarming after deep hypothermia in cardiopulmonary bypass may trigger preterm labor.
• Left atrial thrombus or more than mild mitral regurgitation is a contraindication for percutaneous balloon commissurotomy.
• Stenosis gradients increase during pregnancy; Interpret ECHO findings accordingly.
• Review current medications; Discontinue or change teratogenic or fetotoxic cardiac medications during pregnancy, such as ACE inhibitors and ARBs; Captopril, enalapril and benazepril can be used in breastfeeding after birth, ARB is not recommended.
• Caesarean section prophylaxis also protects against endocarditis; Routine antibiotic prophylaxis is not required for vaginal delivery; some clinicians give it to women with previous infective endocarditis.
• Review the breastfeeding safety of each medication in the breastfeeding woman prior to discharge.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Furosemide (oral): No breastfeeding difficulties have been reported with the low dose (20 mg/day) in breastfeeding.
• Furosemide (oral): Use with caution during pregnancy as excessive diuresis may reduce uterine blood flow and placental perfusion.
• Furosemide (IV): Since excessive diuresis during pregnancy may reduce uterine blood flow and placental perfusion, it is used with caution and the dose is titrated only in cases of pulmonary congestion or volume overload.

Approach

1. Severe symptomatic aortic stenosis is mWHO IV; Pregnancy is not recommended. Write in the record that pregnancy is contraindicated, the lesion-specific rationale, and the patient's understanding and preferences.
2. Evaluate with the Pregnancy Heart Team; Perform detailed history, previous valve interventions, symptom status, physical examination, ECG, ECHO and functional evaluation with a cardiologist experienced in pregnancy and valve disease; Determine valve gradient, ventricular function, exercise capacity, and concomitant aortopathy.
3. Explain to the woman referred for intervention the risks and benefits of each option: if replacement is required, weigh the fetal risks of thromboembolism and anticoagulation in pregnancy with a mechanical valve, limited durability of the bioprosthesis, and the need for reintervention; If appropriate, choose repair over replacement.
4. In bicuspid aortic valve, evaluate the aortic diameter regardless of the severity of stenosis; If the diameter reaches 50 mm, recommend pre-pregnancy aortic surgery (45 mm if cardiac surgery is to be performed for another reason).
5. For a congenital etiology (bicuspid aortic valve), discuss the risk of congenital heart disease in the child (approximately 4–10%) and fetal echocardiography at 18–22 weeks of pregnancy.
6. Provide effective contraception until intervention or optimization is completed; Choose long-acting reversible methods.

Treatment

• Perform valve intervention before pregnancy.

Note

• Review current medications; Discontinue or change teratogenic or fetotoxic heart medications such as ACE inhibitors and ARBs.

Approach

1. Severe symptomatic aortic stenosis is mWHO IV; If pregnancy has occurred, discuss the maternal risk, continuation in a specialist center, and the option of termination if legally and ethically appropriate.
2. If pregnancy persists, concentrate care at a tertiary or quaternary center with advanced cardiac, obstetric, anesthesia, intensive care and neonatal facilities.
3. Perform a comprehensive risk assessment at the first antenatal visit in a woman who has not received pre-pregnancy counseling, with detailed history, previous valve interventions, symptom status, physical examination, ECG, ECHO and functional evaluation; Monitor for heart failure and arrhythmia during pregnancy.
4. Monitor aortic diameter in bicuspid aortic valve throughout pregnancy; If the ascending aorta is > 50 mm, the risk is at mWHO IV level.
5. Monitor fetal growth; in a congenital etiology (bicuspid aortic valve), plan fetal echocardiography at 18–22 weeks (the risk of congenital heart disease in the child is approximately 4–10%).
6. Plan the birth at a reference center with neonatal intensive care facilities; prepare the birth plan in advance and distribute it to the entire team, perform prenatal obstetric anesthesia evaluation and perform continuous telemetry during labor; Intraarterial pressure monitoring may be useful.
7. Plan delivery by minimizing Valsalva with appropriate analgesia; Consider cesarean section in severe symptomatic aortic stenosis and determine the mode of delivery according to the hemodynamic status and obstetric conditions with the Pregnancy Heart Team.
8. Consider monitoring women at highest risk for heart failure or who develop heart failure during pregnancy or birth in intensive (cardiac) care for hemodynamic monitoring for the first 24–48 hours postpartum.
9. Determine frequency of postpartum check-ups based on lesion and symptoms (hemodynamic changes of pregnancy may take up to 6 months to resolve); Choose long-acting reversible methods of contraception (intrauterine device, progestin implant) and individualize the choice according to the lesion, anticoagulation status and bleeding profile.

Treatment

• If symptoms develop during pregnancy, limit physical activity as the first step.
• In pulmonary edema — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in patients who have not previously used diuretics; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• Perform valvuloplasty, percutaneous transcatheter valve implantation, or valve replacement during pregnancy for symptoms resistant to drug therapy.
• If cardiopulmonary bypass is mandatory, apply high flow (2.5 L/min/m²) and mean arterial pressure greater than 70 mmHg.
• If cesarean delivery is to be performed — Cefazolin: 2 g IV as a single dose for weight under 120 kg, or 3 g IV for 120 kg and above, within 60 minutes before skin incision; repeat the dose if the procedure is still ongoing 4 hours after the first dose or if blood loss exceeds 1500 mL; for cesarean delivery performed during labor or after membrane rupture, add azithromycin 500 mg as a single IV infusion in 250 mL of compatible fluid over 1 hour (do not administer as an IV bolus or IM); in severe beta-lactam allergy, administer clindamycin 900 mg IV + gentamicin 5 mg/kg IV single dose instead of cefazolin (if actual weight is more than 20% above ideal weight, dosing weight = ideal weight + 0.4 × (actual weight − ideal weight)); if in labor or membranes are ruptured, add azithromycin in the same manner.

Note

• Consider fetal radiation exposure and risk of maternal and fetal complications during valve intervention during pregnancy; Rewarming after deep hypothermia in cardiopulmonary bypass may trigger preterm labor.
• Stenosis gradients increase during pregnancy; Interpret ECHO findings accordingly.
• Review current medications; Discontinue or change teratogenic or fetotoxic cardiac medications during pregnancy, such as ACE inhibitors and ARBs; Captopril, enalapril and benazepril can be used in breastfeeding after birth, ARB is not recommended.
• Caesarean section prophylaxis also protects against endocarditis; Routine antibiotic prophylaxis is not required for vaginal delivery; some clinicians give it to women with previous infective endocarditis.
• Review the breastfeeding safety of each medication in the breastfeeding woman prior to discharge.
• Furosemide (IV): Since excessive diuresis during pregnancy may reduce uterine blood flow and placental perfusion, it is used with caution and the dose is titrated only in cases of pulmonary congestion or volume overload.

Approach

1. Apply the mWHO IV approach if LVEF < 30% or NYHA III–IV heart failure, regardless of the severity of the valve lesion: recommend avoiding pregnancy; If pregnancy has occurred, discuss the option of terminating it if it is legally and ethically appropriate.
2. Classify risk with mWHO and CARPREG II; Evaluate with the Pregnancy Heart Team; Perform the evaluation with a cardiologist experienced in pregnancy and valve disease: detailed history, previous valve interventions, symptom status, physical examination, ECG, ECHO and functional evaluation.
3. Determine the severity of failure, ventricular dilatation and dysfunction, and pulmonary hypertension by ECHO; Objectively evaluate functional capacity with exercise testing.
4. Explain to the woman referred for intervention the risks and benefits of each option: if replacement is required, weigh the fetal risks of thromboembolism and anticoagulation in pregnancy with a mechanical valve, limited durability of the bioprosthesis, and the need for reintervention; If appropriate, choose repair over replacement.
5. Advise women with moderate valve disease remaining after repair not to delay pregnancy.
6. For a congenital etiology (atrioventricular canal defect), discuss the risk of congenital heart disease in the child (approximately 4–10%) and fetal echocardiography at 18–22 weeks of pregnancy.
7. Provide effective contraception until intervention or optimization is completed; Choose long-acting reversible methods.

Treatment

• Perform surgery before pregnancy if there are symptoms of severe mitral regurgitation, ventricular dysfunction, or significant ventricular dilatation; If appropriate, choose repair over replacement.

Note

• Insufficiency may not change, increase or decrease during pregnancy; Interpret ECHO findings accordingly.
• Review current medications; Discontinue or change teratogenic or fetotoxic heart medications such as ACE inhibitors and ARBs.

Approach

1. Apply the mWHO IV approach if LVEF < 30% or NYHA III–IV heart failure, regardless of the severity of the valve lesion: recommend avoiding pregnancy; If pregnancy has occurred, discuss the option of terminating it if it is legally and ethically appropriate.
2. Classify risk with mWHO and CARPREG II; Evaluate and manage with the Pregnancy Heart Team.
3. Perform a comprehensive risk assessment at the first antenatal visit in a woman who has not received pre-pregnancy counseling, with detailed history, previous valve interventions, symptom status, physical examination, ECG, ECHO and functional evaluation; Assess regurgitation, LV function, and pulmonary pressure by echocardiography and monitor for signs of heart failure.
4. Monitor fetal growth; in a congenital etiology (atrioventricular canal defect), plan fetal echocardiography at 18–22 weeks (the risk of congenital heart disease in the child is approximately 4–10%).
5. Plan the birth at a reference center with neonatal intensive care facilities; Prepare the birth plan in advance and distribute it to the entire team, perform prenatal obstetric anesthesia evaluation and apply continuous telemetry during labor.
6. Plan vaginal delivery with appropriate analgesia, minimizing Valsalva.
7. Consider monitoring women at highest risk for heart failure or who develop heart failure during pregnancy or birth in intensive (cardiac) care for hemodynamic monitoring for the first 24–48 hours postpartum.
8. Determine the frequency of postpartum check-ups according to the lesion and symptoms; It may take up to 6 months for the hemodynamic changes of pregnancy to resolve.
9. Prefer long-acting reversible methods of contraception (intrauterine device, progestin implant); Individualize selection based on lesion, anticoagulation status, and bleeding profile.

Treatment

• If there are signs or symptoms of congestion — Furosemide (oral): 20–40 mg once daily is started; If the response is insufficient, the single dose is adjusted by doubling instead of giving the same dose more frequently; The new dose is given no earlier than 6–8 hours after the previous dose; usual dose 40–240 mg per day; Maximum total daily dose of 600 mg (up to 1000 mg in severe renal impairment).
• Only perform valve surgery during pregnancy if the mother's life is in danger and other treatment methods, including medication, have failed.
• If cardiopulmonary bypass is mandatory, apply high flow (2.5 L/min/m²) and mean arterial pressure greater than 70 mmHg.
• If cesarean delivery is to be performed — Cefazolin: 2 g IV as a single dose for weight under 120 kg, or 3 g IV for 120 kg and above, within 60 minutes before skin incision; repeat the dose if the procedure is still ongoing 4 hours after the first dose or if blood loss exceeds 1500 mL; for cesarean delivery performed during labor or after membrane rupture, add azithromycin 500 mg as a single IV infusion in 250 mL of compatible fluid over 1 hour (do not administer as an IV bolus or IM); in severe beta-lactam allergy, administer clindamycin 900 mg IV + gentamicin 5 mg/kg IV single dose instead of cefazolin (if actual weight is more than 20% above ideal weight, dosing weight = ideal weight + 0.4 × (actual weight − ideal weight)); if in labor or membranes are ruptured, add azithromycin in the same manner.

Note

• Consider fetal radiation exposure and risk of maternal and fetal complications during valve intervention during pregnancy; Rewarming after deep hypothermia in cardiopulmonary bypass may trigger preterm labor.
• Review current medications; Discontinue or change teratogenic or fetotoxic cardiac medications during pregnancy, such as ACE inhibitors and ARBs; Captopril, enalapril and benazepril can be used in breastfeeding after birth, ARB is not recommended.
• Caesarean section prophylaxis also protects against endocarditis; Routine antibiotic prophylaxis is not required for vaginal delivery; some clinicians give it to women with previous infective endocarditis.
• Review the breastfeeding safety of each medication in the breastfeeding woman prior to discharge.
• Furosemide (oral): No breastfeeding difficulties have been reported with the low dose (20 mg/day) in breastfeeding.
• Furosemide (oral): Use with caution during pregnancy as excessive diuresis may reduce uterine blood flow and placental perfusion.

Approach

1. Uncomplicated and permanently stable mechanical valve mWHO III; In CARPREG II, mechanical valve is 3 points.
2. Manage at a specialist center with a Pregnancy Heart Team; Have your cardiology check-up usually every 1-2 months and create your birth plan early.
3. If pre-pregnancy evaluation was not performed, perform detailed history, previous valve interventions, symptom status, physical examination, ECG, ECHO and functional evaluation at the first antenatal visit; Determine valve function, ventricular function, and pulmonary pressure.
4. Perform ECHO every trimester to evaluate valve function and exclude valve thrombosis; A greater than expected increase in gradient, new heart failure, embolic event, syncope, change in valve click, or new murmur requires immediate evaluation.
5. Finalize the anticoagulation plan with the Pregnancy Heart Team as soon as pregnancy is confirmed; Make the choice based on the balance of valve thrombosis and fetal risk and the patient's informed preference.
6. VKA (warfarin) is the most effective drug against valve thrombosis; However, especially in doses above 5 mg/day in the first trimester, it increases the risk of fetal anomalies and is associated with late fetal loss.
7. Explain that early VKA exposure may cause embryopathy and that later exposure may cause fetal bleeding, including intracranial hemorrhage.
8. LMWH has a lower fetal risk but a higher risk of maternal mortality and thromboembolism; Insufficient dose increases the risk of valve thrombosis and requires close anti-Xa monitoring.
9. Monitor fetal growth.
10. Plan the birth at a reference center with neonatal intensive care facilities; Prepare the birth plan in advance and distribute it to the entire team.

Treatment

• Continue VKA with INR monitoring (weekly or at least every 2 weeks).
• Warfarin: target INR (accepted range) — 2.5 (2.0–3.0) if there are no additional prothrombotic factors with bileaflet or newer-generation tilting-disc aortic valves, and 3.0 (2.5–3.5) if present; 3.0 (2.5–3.5) if there are no additional prothrombotic factors with any mechanical valve in the mitral or tricuspid position or any caged-ball or older-generation disc valve in any position, and 3.5 (3.0–4.0) if present; during pregnancy, check INR weekly, or at least every 2 weeks.
• In women who prioritize fetal risk, dose-adjusted therapeutic LMWH twice daily during the 1st trimester (through week 12) is a reasonable option.
• VKA is recommended in the 2nd and 3rd trimesters until the 36th week; In women who prioritize fetal risk, therapeutic dose SC LMWH is a reasonable alternative.
• When switching from LMWH to VKA, continue LMWH with VKA; Discontinue LMWH after INR has been measured within the therapeutic range for two consecutive days.
• When switching to LMWH, discontinue VKA and start therapeutic dose LMWH on the same day.
• Enoxaparin: initially 125 anti‑Xa IU/kg (1.25 mg/kg) SC every 12 hours, then 100 anti‑Xa IU/kg (1 mg/kg) SC every 12 hours.
• Dalteparin: initially 125 IU/kg SC every 12 hours, then 100 IU/kg SC every 12 hours.
• Tinzaparin: initially 250 IU/kg SC, then 175 IU/kg SC once daily.
• Measure the peak anti-Xa level for the first time on day 2 or 3, at 4–6 hours after the dose; individualize target by valve type and location (usually 1.0–1.2 IU/mL; accepted range 0.8–1.2 IU/mL); Also measure the pre-dose (trough) level in selected patients at high risk of thrombosis.
• If anti-Xa is below target, increase dose by 10–20% and remeasure after 48 hours.
• INR usually falls below 1.5 on days 5–7; From this point on, anticoagulation is entirely dependent on LMWH, adjust the dose every 3–7 days with anti‑Xa measurement.
• No fixed time is defined for the transition from the initial dose to the next dose; adjust subsequent doses based on measured peak anti-Xa level.
• Consider adding low-dose aspirin (75–100 mg/day) at very high thrombotic risk.
• For routine pregnancy anticoagulation, use UFH only if LMWH or anti‑Xa monitoring is not available and the patient refuses VKA; UFH is advantageous when creatinine clearance is < 30 mL/min or rapid reversal is required for delivery, neuraxial intervention, or emergency surgery.
• If UFH is used — UFH (IV): in the hospital, start with an infusion of 1000–1250 IU/hour (approximately 18 IU/kg/hour) without loading; If switching from LMWH, it starts 12 hours after the last LMWH dose; Adjusted according to aPTT every 6 hours; target aPTT at least 2 times (2–2.5 times) control.

Note

• Prophylactic dose of LMWH is insufficient for mechanical valve.
• Use enoxaparin or dalteparin schedule when twice daily SC LMWH regimen is selected; Do not mix the once-daily tinzaparin schedule with this two-dose regimen.
• Do not use LMWH without anti-Xa monitoring.
• Do not use DOACs; they are not recommended during pregnancy.
• Review current medications; Discontinue or change teratogenic or fetotoxic cardiac medications during pregnancy, such as ACE inhibitors and ARBs.
• Warfarin: Additional prothrombotic factors: hereditary or acquired hypercoagulability, LVEF <35%, AF with significant mitral stenosis, major thrombotic event in the last 12 months (cardioembolic stroke, DVT, PE); The highest target is applied in multiple mechanical valves.
• UFH (IV): Infusion is stopped 4–6 hours before neuraxial intervention and coagulation is evaluated.

Approach

1. Uncomplicated and permanently stable mechanical valve mWHO III; In CARPREG II, mechanical valve is 3 points.
2. Manage at a specialist center with a Pregnancy Heart Team; Have your cardiology check-up usually every 1-2 months and create your birth plan early.
3. If pre-pregnancy evaluation was not performed, perform detailed history, previous valve interventions, symptom status, physical examination, ECG, ECHO and functional evaluation at the first antenatal visit; Determine valve function, ventricular function, and pulmonary pressure.
4. Perform ECHO every trimester to evaluate valve function and exclude valve thrombosis; A greater than expected increase in gradient, new heart failure, embolic event, syncope, change in valve click, or new murmur requires immediate evaluation.
5. Finalize the anticoagulation plan with the Pregnancy Heart Team as soon as pregnancy is confirmed; Make the choice based on the balance of valve thrombosis and fetal risk and the patient's informed preference.
6. VKA (warfarin) is the most effective drug against valve thrombosis; However, especially in doses above 5 mg/day in the first trimester, it increases the risk of fetal anomalies and is associated with late fetal loss.
7. Explain that early VKA exposure may cause embryopathy and that later exposure may cause fetal bleeding, including intracranial hemorrhage.
8. LMWH has a lower fetal risk but a higher risk of maternal mortality and thromboembolism; Insufficient dose increases the risk of valve thrombosis and requires close anti-Xa monitoring.
9. Monitor fetal growth.
10. Plan the birth at a reference center with neonatal intensive care facilities; Prepare the birth plan in advance and distribute it to the entire team.

Treatment

• Continue VKA (warfarin) in the first trimester with INR monitoring, or switch to dose-adjusted SC LMWH during weeks 5–12; make the choice together with the patient.
• Warfarin: target INR (accepted range) — 2.5 (2.0–3.0) if there are no additional prothrombotic factors with bileaflet or newer-generation tilting-disc aortic valves, and 3.0 (2.5–3.5) if present; 3.0 (2.5–3.5) if there are no additional prothrombotic factors with any mechanical valve in the mitral or tricuspid position or any caged-ball or older-generation disc valve in any position, and 3.5 (3.0–4.0) if present; during pregnancy, check INR weekly, or at least every 2 weeks.
• During pregnancy, measure INR weekly, at least every 2 weeks.
• VKA is recommended in the 2nd and 3rd trimesters until the 36th week; In women who prioritize fetal risk, therapeutic dose SC LMWH is a reasonable alternative.
• When switching from LMWH to VKA, continue LMWH with VKA; Discontinue LMWH after INR has been measured within the therapeutic range for two consecutive days.
• When switching to LMWH, discontinue VKA and start therapeutic dose LMWH on the same day.
• Enoxaparin: initially 125 anti‑Xa IU/kg (1.25 mg/kg) SC every 12 hours, then 100 anti‑Xa IU/kg (1 mg/kg) SC every 12 hours.
• Dalteparin: initially 125 IU/kg SC every 12 hours, then 100 IU/kg SC every 12 hours.
• Tinzaparin: initially 250 IU/kg SC, then 175 IU/kg SC once daily.
• Measure the peak anti-Xa level for the first time on day 2 or 3, at 4–6 hours after the dose; individualize target by valve type and location (usually 1.0–1.2 IU/mL; accepted range 0.8–1.2 IU/mL); Also measure the pre-dose (trough) level in selected patients at high risk of thrombosis.
• If anti-Xa is below target, increase dose by 10–20% and remeasure after 48 hours.
• INR usually falls below 1.5 on days 5–7; From this point on, anticoagulation is entirely dependent on LMWH, adjust the dose every 3–7 days with anti‑Xa measurement.
• No fixed time is defined for the transition from the initial dose to the next dose; adjust subsequent doses based on measured peak anti-Xa level.
• Consider adding low-dose aspirin (75–100 mg/day) at very high thrombotic risk.
• For routine pregnancy anticoagulation, use UFH only if LMWH or anti‑Xa monitoring is not available and the patient refuses VKA; UFH is advantageous when creatinine clearance is < 30 mL/min or rapid reversal is required for delivery, neuraxial intervention, or emergency surgery.
• If UFH is used — UFH (IV): in the hospital, start with an infusion of 1000–1250 IU/hour (approximately 18 IU/kg/hour) without loading; If switching from LMWH, it starts 12 hours after the last LMWH dose; Adjusted according to aPTT every 6 hours; target aPTT at least 2 times (2–2.5 times) control.

Note

• Prophylactic dose of LMWH is insufficient for mechanical valve.
• Use enoxaparin or dalteparin schedule when twice daily SC LMWH regimen is selected; Do not mix the once-daily tinzaparin schedule with this two-dose regimen.
• Do not use LMWH without anti-Xa monitoring.
• Do not use DOACs; they are not recommended during pregnancy.
• Review current medications; Discontinue or change teratogenic or fetotoxic cardiac medications during pregnancy, such as ACE inhibitors and ARBs.
• Warfarin: Additional prothrombotic factors: hereditary or acquired hypercoagulability, LVEF <35%, AF with significant mitral stenosis, major thrombotic event in the last 12 months (cardioembolic stroke, DVT, PE); The highest target is applied in multiple mechanical valves.
• UFH (IV): Infusion is stopped 4–6 hours before neuraxial intervention and coagulation is evaluated.

Approach

1. Uncomplicated and permanently stable mechanical valve mWHO III; In CARPREG II, mechanical valve is 3 points.
2. Manage at a specialist center with a Pregnancy Heart Team; Have your cardiology check-up usually every 1-2 months and create your birth plan early.
3. If pre-pregnancy evaluation was not performed, perform detailed history, previous valve interventions, symptom status, physical examination, ECG, ECHO and functional evaluation at the first antenatal visit; Determine valve function, ventricular function, and pulmonary pressure.
4. Perform ECHO every trimester to evaluate valve function and exclude valve thrombosis; A greater than expected increase in gradient, new heart failure, embolic event, syncope, change in valve click, or new murmur requires immediate evaluation.
5. Finalize the anticoagulation plan with the Pregnancy Heart Team as soon as pregnancy is confirmed; Make the choice based on the balance of valve thrombosis and fetal risk and the patient's informed preference.
6. VKA (warfarin) is the most effective drug against valve thrombosis; However, especially in doses above 5 mg/day in the first trimester, it increases the risk of fetal anomalies and is associated with late fetal loss.
7. Explain that early VKA exposure may cause embryopathy and that later exposure may cause fetal bleeding, including intracranial hemorrhage.
8. LMWH has a lower fetal risk but a higher risk of maternal mortality and thromboembolism; Insufficient dose increases the risk of valve thrombosis and requires close anti-Xa monitoring.
9. Monitor fetal growth.
10. Plan the birth at a reference center with neonatal intensive care facilities; Prepare the birth plan in advance and distribute it to the entire team.

Treatment

• Switch to dose-adjusted, twice-daily therapeutic LMWH in the 1st trimester (as soon as pregnancy is confirmed, through week 12); After the 13th week, return to VKA or continuation of LMWH is determined by mutual decision.
• If a risk factor is present (mechanical mitral/tricuspid valve, AF/flutter, prior thromboembolism, multiple mechanical valves, older-generation valve, prior arrhythmia), consider switching back to a VKA in the 2nd–3rd trimesters until week 36 because of high thrombotic risk.
• If switching to VKA — Warfarin: target INR (accepted range) — 2.5 (2.0–3.0) if there are no additional prothrombotic factors with bileaflet or newer-generation tilting-disc aortic valves, and 3.0 (2.5–3.5) if present; 3.0 (2.5–3.5) if there are no additional prothrombotic factors with any mechanical valve in the mitral or tricuspid position or any caged-ball or older-generation disc valve in any position, and 3.5 (3.0–4.0) if present; during pregnancy, check INR weekly, or at least every 2 weeks.
• During pregnancy, measure INR weekly, at least every 2 weeks.
• When switching from LMWH to VKA, continue LMWH with VKA; Discontinue LMWH after INR has been measured within the therapeutic range for two consecutive days.
• When switching to LMWH, discontinue VKA and start therapeutic dose LMWH on the same day.
• Enoxaparin: initially 125 anti‑Xa IU/kg (1.25 mg/kg) SC every 12 hours, then 100 anti‑Xa IU/kg (1 mg/kg) SC every 12 hours.
• Dalteparin: initially 125 IU/kg SC every 12 hours, then 100 IU/kg SC every 12 hours.
• Tinzaparin: initially 250 IU/kg SC, then 175 IU/kg SC once daily.
• Measure the peak anti-Xa level for the first time on day 2 or 3, at 4–6 hours after the dose; individualize target by valve type and location (usually 1.0–1.2 IU/mL; accepted range 0.8–1.2 IU/mL); Also measure the pre-dose (trough) level in selected patients at high risk of thrombosis.
• If anti-Xa is below target, increase dose by 10–20% and remeasure after 48 hours.
• INR usually falls below 1.5 on days 5–7; From this point on, anticoagulation is entirely dependent on LMWH, adjust the dose every 3–7 days with anti‑Xa measurement.
• No fixed time is defined for the transition from the initial dose to the next dose; adjust subsequent doses based on measured peak anti-Xa level.
• Consider adding low-dose aspirin (75–100 mg/day) at very high thrombotic risk.
• For routine pregnancy anticoagulation, use UFH only if LMWH or anti‑Xa monitoring is not available and the patient refuses VKA; UFH is advantageous when creatinine clearance is < 30 mL/min or rapid reversal is required for delivery, neuraxial intervention, or emergency surgery.
• If UFH is used — UFH (IV): in the hospital, start with an infusion of 1000–1250 IU/hour (approximately 18 IU/kg/hour) without loading; If switching from LMWH, it starts 12 hours after the last LMWH dose; Adjusted according to aPTT every 6 hours; target aPTT at least 2 times (2–2.5 times) control.

Note

• Prophylactic dose of LMWH is insufficient for mechanical valve.
• Use enoxaparin or dalteparin schedule when twice daily SC LMWH regimen is selected; Do not mix the once-daily tinzaparin schedule with this two-dose regimen.
• Do not use LMWH without anti-Xa monitoring.
• Do not use DOACs; they are not recommended during pregnancy.
• Review current medications; Discontinue or change teratogenic or fetotoxic cardiac medications during pregnancy, such as ACE inhibitors and ARBs.
• Warfarin: Additional prothrombotic factors: hereditary or acquired hypercoagulability, LVEF <35%, AF with significant mitral stenosis, major thrombotic event in the last 12 months (cardioembolic stroke, DVT, PE); The highest target is applied in multiple mechanical valves.
• UFH (IV): Infusion is stopped 4–6 hours before neuraxial intervention and coagulation is evaluated.

Approach

1. Confirm the diagnosis: heart failure due to left ventricular systolic dysfunction with LVEF < 45%, not explained by another cause, developing toward the end of pregnancy or in the months following delivery (or miscarriage/pregnancy termination). Do not use the time window between the last month of pregnancy and the 5th month postpartum as a mandatory exclusion criterion.
2. Manage with the Pregnancy Heart Team in the intensive care unit, consisting of cardiology, perinatology, anesthesia, intensive care, cardiac surgery and neonatal specialists.
3. Plan early referral to a center that can provide mechanical circulatory support (VA-ECMO or Impella).
4. Measure BNP/NT‑proBNP and troponin; Elevated troponin is associated with poor prognosis.
5. If the fetus has reached the limit of viability in cardiogenic shock, recommend combined spinal/epidural analgesia or emergency cesarean section under general anesthesia, taking into account the gestational age, accompanying diseases and the facilities of the center; Don't expect refractoriness. Prioritize maternal stabilization before the limit of viability and make the birth decision with the Pregnancy Heart Team.
6. Caesarean section can be performed under VA-ECMO or Impella support.
7. Monitor fetal well-being with umbilical artery and middle cerebral artery (MCA) Doppler.
8. If the fetus has reached viability, perform intermittent or continuous fetal heart rate monitoring during hospitalization for maternal decompensation according to gestational age and clinical status; monitor continuously during anesthesia administration, labor, and delivery. Do not delay maternal stabilization for fetal assessment.
9. Closely monitor the first 24–72 hours after birth as the most critical period.
10. Plan discontinuation of heparin before planned delivery based on dose and risk of thrombosis; for neuraxial intervention, at least 12 hours must elapse after the last prophylactic dose of LMWH and at least 24 hours after the intermediate or therapeutic dose; plan postpartum resumption time if indication persists and there is no significant bleeding or significant risk of bleeding (general obstetric range 4–6 hours after vaginal birth, 6–12 hours after cesarean section).

Treatment

• Dobutamine: Start with 2–5 µg/kg/min IV infusion, titrating to 2–20 µg/kg/min according to response.
• Milrinone: 0.375–0.75 µg/kg/min IV infusion; If creatinine clearance is 10–50 mL/min, start with 0.0625–0.125 µg/kg/min and titrate carefully and do not exceed 0.375 µg/kg/min in significant renal impairment; If creatinine clearance is <10 mL/min, another agent is chosen; Hypotension may be prolonged in renal impairment.
• Levosimendan: 0.1 µg/kg/min IV infusion without loading dose; 0.05–0.2 µg/kg/min depending on response; The recommended infusion time is 24 hours.
• If hypotension persists despite inotrope — Noradrenaline: Start with 0.05 µg/kg/min IV infusion, titrate according to mean arterial pressure and organ perfusion; usual range 0.05–0.4 µg/kg/min, up to 1.0 µg/kg/min if necessary.
• In Hypoxemia — Oxygen: Oxygen is administered if SpO2 is below 90% or PaO2 is below 60 mmHg; SpO2 is maintained at least 90%, preferably 95% or above; If SpO2 remains below 95% despite oxygen or respiratory distress (respiratory rate >25/min) persists, noninvasive positive pressure ventilation is applied; Intubation and invasive ventilation are applied in progressive respiratory failure despite oxygen or noninvasive support.
• In congestion — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in patients who have not used diuretics before; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• Venoarterial ECMO (VA-ECMO) or percutaneous left ventricular assist device (Impella): apply as a bridge to transplant or myocardial recovery in inotrope-resistant shock.
• If LVEF < 35% or intracardiac thrombus, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• If therapeutic anticoagulation is not applied and thromboprophylaxis is indicated (inpatient) — Enoxaparin (prophylactic): 40 mg SC once a day for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance is < 30 mL/min or if rapid reversal may be required for labor, neuraxial anesthesia, or emergency surgery, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH — UFH (SC, prophylactic): 5000–7500 IU in the 1st trimester, 7500–10 000 IU in the 2nd trimester, 10 000 IU SC every 12 hours in the 3rd trimester (dose is reduced if aPTT is prolonged).
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).

Note

• ACE inhibitor, ARB and ARNI are contraindicated during pregnancy.
• Avoid spironolactone during pregnancy; Review current therapy due to possible antiandrogenic effects and limited pregnancy safety data.
• Do not administer vasodilators in hypotension or cardiogenic shock.
• If UFH is used, before neuraxial intervention: stop IV infusion at least 4–6 hours before; Wait 4–6 hours after SC 5000 IU (2–3 times a day), wait 12 hours after SC 7500–10 000 IU every 12 hours, wait 24 hours after single dose > 10 000 IU or total daily > 20 000 IU; In all cases, verify that coagulation (aPTT) is normal before intervention. Check platelet count if UFH has been used for more than 4 days.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Milrinone: Since it crosses the placenta during pregnancy, it is used only when the benefit outweighs the risk.
• Levosimendan: Not used in creatinine clearance <30 mL/min, severe liver failure, significant mechanical obstruction affecting ventricular filling or outflow, history of torsade de pointes, severe hypotension, and tachycardia; In hypotension, if necessary, it is given together with noradrenaline; The hemodynamic effect may last up to 9 days after the 24-hour infusion ends.
• Furosemide (IV): Since excessive diuresis during pregnancy may reduce uterine blood flow and placental perfusion, it is used with caution and the dose is titrated only in cases of pulmonary congestion or volume overload.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Confirm the diagnosis: heart failure due to left ventricular systolic dysfunction with LVEF < 45%, not explained by another cause, developing toward the end of pregnancy or in the months following delivery (or miscarriage/pregnancy termination). Do not use the time window between the last month of pregnancy and the 5th month postpartum as a mandatory exclusion criterion.
2. Manage with the Pregnancy Heart Team; Prepare the birth plan in writing with the team.
3. Measure BNP/NT‑proBNP and troponin; Elevated troponin is associated with poor prognosis.
4. Vaginal delivery is recommended for most cardiomyopathies; Caesarean section is preferred if there is obstetric indication, severe heart failure (LVEF < 30% and/or NYHA III–IV), uncontrolled arrhythmia, outflow tract obstruction ≥ 50 mmHg in HCM, or labor under VKA (warfarin).
5. Initiate epidural analgesia early in labor and maintain it rigorously; It reduces systemic vascular resistance and provides an advantage in left ventricular systolic dysfunction.
6. Use assisted vaginal birth in conjunction with cardiology according to individual risk assessment to shorten the second stage.
7. Monitor fetal growth with serial USG and fetal well-being with umbilical artery and middle cerebral artery (MCA) Doppler.
8. If the fetus has reached viability, perform intermittent or continuous fetal heart rate monitoring during hospitalization for maternal decompensation according to gestational age and clinical status; monitor continuously during anesthesia administration, labor, and delivery. Do not delay maternal stabilization for fetal assessment.
9. Closely monitor the first 24–72 hours after birth as the most critical period.
10. Plan discontinuation of heparin before planned delivery based on dose and risk of thrombosis; for neuraxial intervention, at least 12 hours must elapse after the last prophylactic dose of LMWH and at least 24 hours after the intermediate or therapeutic dose; plan postpartum resumption time if indication persists and there is no significant bleeding or significant risk of bleeding (general obstetric range 4–6 hours after vaginal birth, 6–12 hours after cesarean section).

Treatment

• After resolution of acute pulmonary edema, in stable and euvolemic patient — Metoprolol succinate (long-acting, oral): Start at 25 mg once daily in NYHA II, 12.5 mg once daily in more severe heart failure; If tolerated, double the dose every 2 weeks to a maximum of 200 mg once a day.
• After resolution of acute pulmonary edema, in stable and euvolemic patient — Bisoprolol: 1.25 mg once daily is started; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Hydralazine + isosorbide dinitrate (oral): start with hydralazine 25–37.5 mg and isosorbide dinitrate 20 mg 3 times daily; Target hydralazine 75 mg and isosorbide dinitrate 40 mg 3 times a day, increasing every 1–2 weeks.
• If IV nitrate is required — Nitroglycerin: Start with 5 µg/min IV infusion, increasing every 3–5 minutes to a maximum of 100 µg/min; It is given together with a diuretic.
• In pulmonary edema — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in patients who have not previously used diuretics; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• In mild, stable congestion in the absence of acute pulmonary edema — Furosemide (oral): 20–40 mg once daily is started; If the response is insufficient, the single dose is adjusted by doubling instead of giving the same dose more frequently; The new dose is given no earlier than 6–8 hours after the previous dose; usual dose 40–240 mg per day; Maximum total daily dose of 600 mg (up to 1000 mg in severe renal impairment).
• If LVEF < 35% or intracardiac thrombus, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• If therapeutic anticoagulation is not applied and thromboprophylaxis is indicated (inpatient) — Enoxaparin (prophylactic): 40 mg SC once a day for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance < 30 mL/min, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH — UFH (SC, prophylactic): 5000–7500 IU in the 1st trimester, 7500–10 000 IU in the 2nd trimester, 10 000 IU SC every 12 hours in the 3rd trimester (dose is reduced if aPTT is prolonged).
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).
• Immediately after birth — Enalapril: Start at 2.5 mg twice daily; The target is 10–20 mg twice a day, doubling the dose every 1–2 weeks.

Note

• Use only cardioselective beta blockers (metoprolol, bisoprolol) during pregnancy.
• ACE inhibitor, ARB and ARNI are contraindicated during pregnancy.
• Avoid spironolactone during pregnancy; Review current therapy due to possible antiandrogenic effects and limited pregnancy safety data.
• Cardiac MRI is safe; do not use gadolinium during pregnancy.
• Monitor the newborn of a mother using beta blockers for bradycardia and hypoglycemia.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• If UFH is used, before neuraxial intervention: stop IV infusion at least 4–6 hours before; Wait 4–6 hours after SC 5000 IU (2–3 times a day), wait 12 hours after SC 7500–10 000 IU every 12 hours, wait 24 hours after single dose > 10 000 IU or total daily > 20 000 IU; In all cases, verify that coagulation (aPTT) is normal before intervention. Check platelet count if UFH has been used for more than 4 days.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Metoprolol succinate (long-acting, oral): Started only in stable and euvolemic patients; It is not started new in acute decompensated heart failure; In symptomatic bradycardia, the dose is reduced.
• Bisoprolol: Started only in stable and euvolemic patients.
• Nitroglycerin: Start if systolic BP is above 110 mmHg.
• Furosemide (IV): Since excessive diuresis during pregnancy may reduce uterine blood flow and placental perfusion, it is used with caution and the dose is titrated only in cases of pulmonary congestion or volume overload.
• Furosemide (oral): No breastfeeding difficulties have been reported with the low dose (20 mg/day) in breastfeeding.
• Furosemide (oral): Use with caution during pregnancy as excessive diuresis may reduce uterine blood flow and placental perfusion.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.
• Oxytocin: Slow infusion is used instead of rapid bolus.
• Enalapril: Contraindicated in pregnancy; Can be used during breastfeeding. If serum sodium is <130 mEq/L or serum creatinine is >1.6 mg/dL, start with 2.5 mg once daily under close supervision; The dose is increased every 4 days at the earliest unless there is severe hypotension or significant deterioration of renal function.

Approach

1. Confirm the diagnosis: heart failure due to left ventricular systolic dysfunction with LVEF < 45%, not explained by another cause, developing toward the end of pregnancy or in the months following delivery (or miscarriage/pregnancy termination). Do not use the time window between the last month of pregnancy and the 5th month postpartum as a mandatory exclusion criterion.
2. Manage with the Pregnancy Heart Team in the intensive care unit, consisting of cardiology, perinatology, anesthesia, intensive care, cardiac surgery and neonatal specialists.
3. Plan early referral to a center that can provide mechanical circulatory support (VA-ECMO or Impella).
4. Measure BNP/NT‑proBNP and troponin; Elevated troponin is associated with poor prognosis.
5. Closely monitor the first 24–72 hours after birth as the most critical period.
6. In subsequent pregnancy counseling, indicate that more than mild residual left ventricular dysfunction is mWHO IV (risk of recurrence may reach 50%, maternal mortality 15–20%) and recommend avoiding pregnancy.
7. Maximum risk of mild residual dysfunction is mWHO III; Individualize recurrence risk and pregnancy recommendation with the Pregnancy Heart Team.
8. State that even with full recovery of LVEF above 50%, the risk of relapse in a new pregnancy is approximately 20%; Detailed informed consent and multidisciplinary management are required.
9. If anticoagulation remains indicated and there is no significant bleeding or significant risk of bleeding, plan for postpartum resumption; The general obstetric range is 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
10. Write the indication for anticoagulation and the end/reassessment date in the discharge plan: If anticoagulation is administered due to LVEF < 35%, continue for at least 6 weeks postpartum and reassess based on LVEF; If bromocriptine is used, maintain at least a prophylactic dose of LMWH throughout treatment; In case of intracardiac thrombus, embolism or permanent indication, the expert team determines the duration.

Treatment

• Dobutamine: Start with 2–5 µg/kg/min IV infusion, titrating to 2–20 µg/kg/min according to response.
• Milrinone: 0.375–0.75 µg/kg/min IV infusion; If creatinine clearance is 10–50 mL/min, start with 0.0625–0.125 µg/kg/min and titrate carefully and do not exceed 0.375 µg/kg/min in significant renal impairment; If creatinine clearance is <10 mL/min, another agent is chosen; Hypotension may be prolonged in renal impairment.
• Levosimendan: 0.1 µg/kg/min IV infusion without loading dose; 0.05–0.2 µg/kg/min depending on response; The recommended infusion time is 24 hours.
• If hypotension persists despite inotrope — Noradrenaline: Start with 0.05 µg/kg/min IV infusion, titrate according to mean arterial pressure and organ perfusion; usual range 0.05–0.4 µg/kg/min, up to 1.0 µg/kg/min if necessary.
• In Hypoxemia — Oxygen: Oxygen is administered if SpO2 is below 90% or PaO2 is below 60 mmHg; SpO2 is maintained at least 90%, preferably 95% or above; If SpO2 remains below 95% despite oxygen or respiratory distress (respiratory rate >25/min) persists, noninvasive positive pressure ventilation is applied; Intubation and invasive ventilation are applied in progressive respiratory failure despite oxygen or noninvasive support.
• In congestion — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in patients who have not used diuretics before; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• Venoarterial ECMO (VA-ECMO) or percutaneous left ventricular assist device (Impella): apply as a bridge to transplant or myocardial recovery in inotrope-resistant shock.
• Bromocriptine may be considered in moderate–severe PPCM: 2.5 mg twice daily for 2 weeks, followed by 2.5 mg once daily for 6 weeks; Add at least prophylactic dose of LMWH.
• If LVEF < 35% or intracardiac thrombus, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• If therapeutic anticoagulation is not applied and thromboprophylaxis is indicated (inpatient, bromocriptine use) — Enoxaparin (prophylactic): 40 mg SC once a day for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance < 30 mL/min, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH — UFH (SC, prophylactic): 5000 IU SC every 8–12 hours after birth.
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• Breastfeeding is controversial; bromocriptine suppresses milk production and breastfeeding cannot be continued during treatment; Discuss the baby's feeding plan before treatment.
• Bromocriptine is not used in uncontrolled hypertension; If you have preeclampsia/eclampsia or postpartum hypertension, make use decisions with the Pregnancy Heart Team. Monitor blood pressure, especially in the first days and during dose increases; In case of new hypertension, severe or persistent headache, visual impairment, or chest pain, discontinue the medication and seek immediate evaluation.
• If bromocriptine is considered if LVEF ≥ 30% with severe shock, individualize the dosing schedule with the specialist team.
• Excessive diuresis reduces intravascular volume; Titrate furosemide dose.
• Do not administer vasodilators in hypotension or cardiogenic shock.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• Combined oral contraceptive is strictly contraindicated.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Levosimendan: Not used in creatinine clearance <30 mL/min, severe liver failure, significant mechanical obstruction affecting ventricular filling or outflow, history of torsade de pointes, severe hypotension, and tachycardia; In hypotension, if necessary, it is given together with noradrenaline; The hemodynamic effect may last up to 9 days after the 24-hour infusion ends.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.

Approach

1. Confirm the diagnosis: heart failure due to left ventricular systolic dysfunction with LVEF < 45%, not explained by another cause, developing toward the end of pregnancy or in the months following delivery (or miscarriage/pregnancy termination). Do not use the time window between the last month of pregnancy and the 5th month postpartum as a mandatory exclusion criterion.
2. Watch with the Pregnancy Heart Team.
3. Measure BNP/NT‑proBNP and troponin; Elevated troponin is associated with poor prognosis.
4. Closely monitor the first 24–72 hours after birth as the most critical period.
5. In subsequent pregnancy counseling, indicate that more than mild residual left ventricular dysfunction is mWHO IV (risk of recurrence may reach 50%, maternal mortality 15–20%) and recommend avoiding pregnancy.
6. Maximum risk of mild residual dysfunction is mWHO III; Individualize recurrence risk and pregnancy recommendation with the Pregnancy Heart Team.
7. State that even with full recovery of LVEF above 50%, the risk of relapse in a new pregnancy is approximately 20%; Detailed informed consent and multidisciplinary management are required.
8. If anticoagulation remains indicated and there is no significant bleeding or significant risk of bleeding, plan for postpartum resumption; The general obstetric range is 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
9. Write the indication for anticoagulation and the end/reassessment date in the discharge plan: If anticoagulation is administered due to LVEF < 35%, continue for at least 6 weeks postpartum and reassess based on LVEF; If bromocriptine is used, maintain at least a prophylactic dose of LMWH throughout treatment; In case of intracardiac thrombus, embolism or permanent indication, the expert team determines the duration.

Treatment

• Immediately after birth — Enalapril: Start at 2.5 mg twice daily; The target is 10–20 mg twice a day, doubling the dose every 1–2 weeks.
• After resolution of acute pulmonary edema, in stable and euvolemic patient — Metoprolol succinate (long-acting, oral): Start at 25 mg once daily in NYHA II, 12.5 mg once daily in more severe heart failure; If tolerated, double the dose every 2 weeks to a maximum of 200 mg once a day.
• After resolution of acute pulmonary edema, in stable and euvolemic patient — Bisoprolol: 1.25 mg once daily is started; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• In pulmonary edema — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in patients who have not previously used diuretics; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• In mild, stable congestion in the absence of acute pulmonary edema — Furosemide (oral): 20–40 mg once daily is started; If the response is insufficient, the single dose is adjusted by doubling instead of giving the same dose more frequently; The new dose is given no earlier than 6–8 hours after the previous dose; usual dose 40–240 mg per day; Maximum total daily dose of 600 mg (up to 1000 mg in severe renal impairment).
• Bromocriptine may be considered in moderate–severe PPCM: 2.5 mg twice daily for 2 weeks, followed by 2.5 mg once daily for 6 weeks; Add at least prophylactic dose of LMWH.
• If LVEF < 35% or intracardiac thrombus, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• If therapeutic anticoagulation is not applied and thromboprophylaxis is indicated (inpatient, bromocriptine use) — Enoxaparin (prophylactic): 40 mg SC once a day for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance < 30 mL/min, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH — UFH (SC, prophylactic): 5000 IU SC every 8–12 hours after birth.
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• Breastfeeding is controversial; bromocriptine suppresses milk production and breastfeeding cannot be continued during treatment; Discuss the baby's feeding plan before treatment.
• Bromocriptine is not used in uncontrolled hypertension; If you have preeclampsia/eclampsia or postpartum hypertension, make use decisions with the Pregnancy Heart Team. Monitor blood pressure, especially in the first days and during dose increases; In case of new hypertension, severe or persistent headache, visual impairment, or chest pain, discontinue the medication and seek immediate evaluation.
• Excessive diuresis reduces intravascular volume; Titrate furosemide dose.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• Combined oral contraceptive is strictly contraindicated.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Enalapril: Contraindicated in pregnancy; Can be used during breastfeeding. If serum sodium is <130 mEq/L or serum creatinine is >1.6 mg/dL, start with 2.5 mg once daily under close supervision; The dose is increased every 4 days at the earliest unless there is severe hypotension or significant deterioration of renal function.
• Metoprolol succinate (long-acting, oral): Started only in stable and euvolemic patients; It is not started new in acute decompensated heart failure; In symptomatic bradycardia, the dose is reduced.
• Bisoprolol: Started only in stable and euvolemic patients.
• Furosemide (oral): No breastfeeding difficulties have been reported with the low dose (20 mg/day) in breastfeeding.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.

Approach

1. Confirm the diagnosis: heart failure due to left ventricular systolic dysfunction with LVEF < 45%, not explained by another cause, developing toward the end of pregnancy or in the months following delivery (or miscarriage/pregnancy termination). Do not use the time window between the last month of pregnancy and the 5th month postpartum as a mandatory exclusion criterion.
2. Watch with the Pregnancy Heart Team.
3. Measure BNP/NT‑proBNP and troponin; Elevated troponin is associated with poor prognosis.
4. Closely monitor the first 24–72 hours after birth as the most critical period.
5. In subsequent pregnancy counseling, indicate that more than mild residual left ventricular dysfunction is mWHO IV (risk of recurrence may reach 50%, maternal mortality 15–20%) and recommend avoiding pregnancy.
6. Maximum risk of mild residual dysfunction is mWHO III; Individualize recurrence risk and pregnancy recommendation with the Pregnancy Heart Team.
7. State that even with full recovery of LVEF above 50%, the risk of relapse in a new pregnancy is approximately 20%; Detailed informed consent and multidisciplinary management are required.
8. If anticoagulation remains indicated and there is no significant bleeding or significant risk of bleeding, plan for postpartum resumption; The general obstetric range is 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
9. Write the indication for anticoagulation and the end/reassessment date in the discharge plan: If anticoagulation is administered due to LVEF < 35%, continue for at least 6 weeks postpartum and reassess based on LVEF; If bromocriptine is used, maintain at least a prophylactic dose of LMWH throughout treatment; In case of intracardiac thrombus, embolism or permanent indication, the expert team determines the duration.

Treatment

• Immediately after birth — Enalapril: Start at 2.5 mg twice daily; The target is 10–20 mg twice a day, doubling the dose every 1–2 weeks.
• After resolution of acute pulmonary edema, in stable and euvolemic patient — Metoprolol succinate (long-acting, oral): Start at 25 mg once daily in NYHA II, 12.5 mg once daily in more severe heart failure; If tolerated, double the dose every 2 weeks to a maximum of 200 mg once a day.
• After resolution of acute pulmonary edema, in stable and euvolemic patient — Bisoprolol: 1.25 mg once daily is started; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• In pulmonary edema — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in patients who have not previously used diuretics; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• In mild, stable congestion in the absence of acute pulmonary edema — Furosemide (oral): 20–40 mg once daily is started; If the response is insufficient, the single dose is adjusted by doubling instead of giving the same dose more frequently; The new dose is given no earlier than 6–8 hours after the previous dose; usual dose 40–240 mg per day; Maximum total daily dose of 600 mg (up to 1000 mg in severe renal impairment).
• If bromocriptine is considered: 2.5 mg twice daily for 2 weeks, then 2.5 mg once daily for 6 weeks if LVEF ≥ 25% and < 30%; If LVEF > 30%, 2.5 mg once daily for 1 week; In all cases, use at least the prophylactic dose of LMWH.
• If LVEF < 35% or intracardiac thrombus, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• If therapeutic anticoagulation is not applied and thromboprophylaxis is indicated (inpatient, bromocriptine use) — Enoxaparin (prophylactic): 40 mg SC once a day for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance < 30 mL/min, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH — UFH (SC, prophylactic): 5000 IU SC every 8–12 hours after birth.
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• Breastfeeding is controversial; bromocriptine suppresses milk production and breastfeeding cannot be continued during treatment; Discuss the baby's feeding plan before treatment.
• Bromocriptine is not used in uncontrolled hypertension; If you have preeclampsia/eclampsia or postpartum hypertension, make use decisions with the Pregnancy Heart Team. Monitor blood pressure, especially in the first days and during dose increases; In case of new hypertension, severe or persistent headache, visual impairment, or chest pain, discontinue the medication and seek immediate evaluation.
• In mild disease with LVEF > 30%, breastfeeding may be allowed with close monitoring if function improves rapidly.
• If LVEF is exactly 30%, individualize the dosing schedule with the expert team.
• Excessive diuresis reduces intravascular volume; Titrate furosemide dose.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• Combined oral contraceptive is strictly contraindicated.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Enalapril: Contraindicated in pregnancy; Can be used during breastfeeding. If serum sodium is <130 mEq/L or serum creatinine is >1.6 mg/dL, start with 2.5 mg once daily under close supervision; The dose is increased every 4 days at the earliest unless there is severe hypotension or significant deterioration of renal function.
• Metoprolol succinate (long-acting, oral): Started only in stable and euvolemic patients; It is not started new in acute decompensated heart failure; In symptomatic bradycardia, the dose is reduced.
• Bisoprolol: Started only in stable and euvolemic patients.
• Furosemide (oral): No breastfeeding difficulties have been reported with the low dose (20 mg/day) in breastfeeding.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.

Approach

1. Risk class: mWHO III (high risk); Complete recovery does not eliminate the risk of recurrence.
2. Explain that the risk of recurrence in a new pregnancy is approximately 20%; Obtain detailed informed consent.
3. Manage with the multidisciplinary Pregnancy Heart Team from pre-pregnancy.
4. Explain that if pregnancy occurs, close ECHO monitoring will be required at the reference center; individualize viewing.
5. Document NYHA class, ECG, ECHO and baseline BNP/NT‑proBNP before pregnancy.
6. If pregnancy planning is continued, complete medication changes before pregnancy and verify cardiac stability on the new regimen.

Treatment

• Beta blocker required — Metoprolol succinate (long-acting, oral): Start at 25 mg once daily in NYHA II, 12.5 mg once daily in more severe heart failure; If tolerated, double the dose every 2 weeks to a maximum of 200 mg once a day.
• Beta blocker required — Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Effective contraception: use a progestin implant or levonorgestrel-releasing intrauterine device until pregnancy is planned.

Note

• If pregnancy is planned, discontinue ACE inhibitors, ARBs and ARNIs before conception.
• Avoid spironolactone.
• Avoid atenolol if beta blocker is required.
• Combined hormonal contraceptive is contraindicated in the first 6 months after PPCM or NYHA III–IV dysfunction; If function is normal or slightly impaired and at least 6 months have passed, it is generally not recommended; Prefer progestin methods.
• Metoprolol succinate (long-acting, oral): Started only in stable and euvolemic patients; It is not started new in acute decompensated heart failure; In symptomatic bradycardia, the dose is reduced.
• Bisoprolol: Started only in stable and euvolemic patients.

Approach

1. Risk class: mWHO III; Make close ECHO monitoring at the reference center.
2. The risk of recurrence is approximately 20%; Manage with the multidisciplinary Pregnancy Heart Team.
3. Consider paroxysmal nocturnal dyspnea, persistent cough, chest pain, and significant tachycardia as red flags; look for jugular venous distension, basal crackles and an S3 gallop.
4. Measure BNP/NT‑proBNP when relapse is suspected; normal value makes PPCM unlikely, significant elevation favors heart failure.
5. Monitor fetal growth with serial USG.
6. If the fetus has reached viability, perform intermittent or continuous fetal heart rate monitoring during hospitalization for maternal decompensation according to gestational age and clinical status; monitor continuously during anesthesia administration, labor, and delivery. Do not delay maternal stabilization for fetal assessment.
7. Prepare a written birth plan with the Pregnancy Heart Team by approximately week 32.
8. Vaginal delivery is recommended for most cardiomyopathies; Caesarean section is preferred if there is obstetric indication, severe heart failure (LVEF < 30% and/or NYHA III–IV), uncontrolled arrhythmia, outflow tract obstruction ≥ 50 mmHg in HCM, or labor under VKA (warfarin).
9. Initiate epidural analgesia early in labor and maintain it meticulously.
10. Use assisted vaginal birth in conjunction with cardiology according to individual risk assessment to shorten the second stage.
11. Closely monitor the first 24–72 hours after birth as the most critical period.

Treatment

• Beta blocker required — Metoprolol succinate (long-acting, oral): Start at 25 mg once daily in NYHA II, 12.5 mg once daily in more severe heart failure; If tolerated, double the dose every 2 weeks to a maximum of 200 mg once a day.
• Beta blocker required — Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• ACE inhibitor, ARB and ARNI are contraindicated during pregnancy.
• Avoid spironolactone during pregnancy; Review current therapy due to possible antiandrogenic effects and limited pregnancy safety data.
• If beta blockers are used, monitor the newborn for bradycardia and hypoglycemia.
• Combined oral contraceptive is strictly contraindicated.
• Metoprolol succinate (long-acting, oral): Started only in stable and euvolemic patients; It is not started new in acute decompensated heart failure; In symptomatic bradycardia, the dose is reduced.
• Bisoprolol: Started only in stable and euvolemic patients.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Risk class: mWHO III.
2. Individualize risk of relapse and mortality and pregnancy recommendation with the Pregnancy Heart Team; Obtain detailed informed consent.
3. If LVEF is exactly 50%, evaluate pregnancy risk and recommendation for subsequent pregnancy individually with the Pregnancy Heart Team.
4. State in counseling that complications are common and intensive antenatal, intrapartum and postpartum monitoring is required.
5. Manage with the multidisciplinary Pregnancy Heart Team at the specialist center from pre-pregnancy.
6. Document NYHA class, ECG, ECHO and baseline BNP/NT‑proBNP before pregnancy.
7. If pregnancy planning is continued, complete medication changes before pregnancy and verify cardiac stability on the new regimen.

Treatment

• If pregnancy is planned and afterload reduction is to be maintained, instead of ACE inhibitor, ARB, or ARNI — Hydralazine + isosorbide dinitrate (oral): start with hydralazine 25–37.5 mg and isosorbide dinitrate 20 mg 3 times daily; Target hydralazine 75 mg and isosorbide dinitrate 40 mg 3 times a day, increasing every 1–2 weeks.
• Beta blocker required — Metoprolol succinate (long-acting, oral): Start at 25 mg once daily in NYHA II, 12.5 mg once daily in more severe heart failure; If tolerated, double the dose every 2 weeks to a maximum of 200 mg once a day.
• Beta blocker required — Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Effective contraception: use a progestin implant or levonorgestrel-releasing intrauterine device until pregnancy is planned.

Note

• If pregnancy is planned, discontinue ACE inhibitors, ARBs and ARNIs before conception.
• Avoid spironolactone.
• Avoid atenolol if beta blocker is required.
• Combined hormonal contraceptive is contraindicated in the first 6 months after PPCM or NYHA III–IV dysfunction; If function is normal or slightly impaired and at least 6 months have passed, it is generally not recommended; Prefer progestin methods.
• Metoprolol succinate (long-acting, oral): Started only in stable and euvolemic patients; It is not started new in acute decompensated heart failure; In symptomatic bradycardia, the dose is reduced.
• Bisoprolol: Started only in stable and euvolemic patients.

Approach

1. Risk class: mWHO III; Manage with the Pregnancy Heart Team at the specialist centre.
2. Perform cardiology follow-up usually every 1–2 months; Monitor ventricular function with ECHO, individualizing the frequency of checks according to symptoms, functional status and ventricular function.
3. If LVEF is exactly 50%, evaluate pregnancy risk individually with the Pregnancy Heart Team.
4. Monitor for red flags (paroxysmal nocturnal dyspnea, persistent cough, chest pain, marked tachycardia, jugular venous distention, basal rales, S3 gallop); When in doubt, measure BNP/NT‑proBNP.
5. Prepare a written birth plan with the Pregnancy Heart Team by approximately week 32.
6. Vaginal delivery is recommended for most cardiomyopathies; Caesarean section is preferred if there is obstetric indication, severe heart failure (LVEF < 30% and/or NYHA III–IV), uncontrolled arrhythmia, outflow tract obstruction ≥ 50 mmHg in HCM, or labor under VKA (warfarin).
7. Initiate epidural analgesia early in labor and maintain it rigorously; It reduces systemic vascular resistance and provides an advantage in left ventricular systolic dysfunction.
8. Use assisted vaginal birth in conjunction with cardiology according to individual risk assessment to shorten the second stage.
9. Monitor fetal growth with serial USG and fetal well-being with umbilical artery and middle cerebral artery (MCA) Doppler.
10. If the fetus has reached viability, perform intermittent or continuous fetal heart rate monitoring during hospitalization for maternal decompensation according to gestational age and clinical status; monitor continuously during anesthesia administration, labor, and delivery. Do not delay maternal stabilization for fetal assessment.
11. Closely monitor the first 24–72 hours after birth as the most critical period.
12. If acute pulmonary edema or hypoperfusion develops, switch to an acute decompensated heart failure approach.
13. If anticoagulation is administered, plan discontinuation of heparin before planned delivery according to dose and risk of thrombosis (for neuroaxial intervention, at least 12 hours should elapse from the last prophylactic LMWH dose and at least 24 hours from the intermediate or therapeutic dose); plan postpartum resumption time if indication persists and there is no significant bleeding or significant risk of bleeding (general obstetric range 4–6 hours after vaginal birth, 6–12 hours after cesarean section).
14. Write the indication for anticoagulation and the end/reassessment date in the discharge plan: If anticoagulation is administered due to LVEF < 35%, continue for at least 6 weeks postpartum and reassess based on LVEF; If bromocriptine is used, maintain at least a prophylactic dose of LMWH throughout treatment; In case of intracardiac thrombus, embolism or permanent indication, the expert team determines the duration.

Treatment

• Metoprolol succinate (long-acting, oral): Start at 25 mg once daily in NYHA II, 12.5 mg once daily in more severe heart failure; If tolerated, double the dose every 2 weeks to a maximum of 200 mg once a day.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Hydralazine + isosorbide dinitrate (oral): start with hydralazine 25–37.5 mg and isosorbide dinitrate 20 mg 3 times daily; Target hydralazine 75 mg and isosorbide dinitrate 40 mg 3 times a day, increasing every 1–2 weeks.
• If IV nitrate is required — Nitroglycerin: Start with 5 µg/min IV infusion, increasing every 3–5 minutes to a maximum of 100 µg/min; It is given together with a diuretic.
• If congestion develops — Furosemide (oral): 20–40 mg once daily is started; If the response is insufficient, the single dose is adjusted by doubling instead of giving the same dose more frequently; The new dose is given no earlier than 6–8 hours after the previous dose; usual dose 40–240 mg per day; Maximum total daily dose of 600 mg (up to 1000 mg in severe renal impairment).
• After birth, in hemodynamically stable patient — Enalapril: 2.5 mg twice daily is started; The target is 10–20 mg twice a day, doubling the dose every 1–2 weeks.
• If documented intracardiac thrombus or LVEF < 35%, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• In other cases, if thromboprophylaxis is to be applied by individual decision — Enoxaparin (prophylactic): 40 mg SC once a day under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance < 30 mL/min, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH during pregnancy — UFH (SC, prophylactic): 5000–7500 IU in the 1st trimester, 7500–10 000 IU in the 2nd trimester, 10 000 IU SC every 12 hours in the 3rd trimester (dose is reduced if aPTT is prolonged).
• If creatinine clearance is < 30 mL/min, instead of postpartum prophylactic LMWH — UFH (SC, prophylactic): postpartum 5000 IU SC every 8–12 hours.
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• ACE inhibitor, ARB and ARNI are contraindicated in pregnancy; If using it, stop it.
• Avoid spironolactone during pregnancy; Review current therapy due to possible antiandrogenic effects and limited pregnancy safety data.
• Use only cardioselective beta blockers (metoprolol, bisoprolol) during pregnancy.
• Monitor the newborn of a mother using beta blockers for bradycardia and hypoglycemia.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• Combined oral contraceptive is strictly contraindicated.
• If UFH is used, before neuraxial intervention: stop IV infusion at least 4–6 hours before; Wait 4–6 hours after SC 5000 IU (2–3 times a day), wait 12 hours after SC 7500–10 000 IU every 12 hours, wait 24 hours after single dose > 10 000 IU or total daily > 20 000 IU; In all cases, verify that coagulation (aPTT) is normal before intervention. Check platelet count if UFH has been used for more than 4 days.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Metoprolol succinate (long-acting, oral): Started only in stable and euvolemic patients; It is not started new in acute decompensated heart failure; In symptomatic bradycardia, the dose is reduced.
• Bisoprolol: Started only in stable and euvolemic patients.
• Nitroglycerin: Start if systolic BP is above 110 mmHg.
• Furosemide (oral): No breastfeeding difficulties have been reported with the low dose (20 mg/day) in breastfeeding.
• Furosemide (oral): Use with caution during pregnancy as excessive diuresis may reduce uterine blood flow and placental perfusion.
• Enalapril: Contraindicated in pregnancy; Can be used during breastfeeding. If serum sodium is <130 mEq/L or serum creatinine is >1.6 mg/dL, start with 2.5 mg once daily under close supervision; The dose is increased every 4 days at the earliest unless there is severe hypotension or significant deterioration of renal function.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Risk class: mWHO IV; Recommend avoiding pregnancy.
2. Explain that the risk of recurrence in a new pregnancy can reach 50% and maternal mortality can reach 15–20%.
3. Address fetal effects, uncertainty of evidence, reproductive alternatives, and effective contraception in counseling with the expert multidisciplinary team.
4. Clearly state in the record that pregnancy is contraindicated, the rationale, and the patient's understanding and preferences.
5. Recommend tubal ligation; Share the decision without forcing it and evaluate the procedure and anesthesia risk in advance.
6. If pregnancy planning is continued, complete medication changes before pregnancy and verify cardiac stability on the new regimen.

Treatment

• If the woman still plans pregnancy, instead of ACE inhibitor, ARB and ARNI — Hydralazine + isosorbide dinitrate (oral): start with hydralazine 25–37.5 mg and isosorbide dinitrate 20 mg 3 times daily; Target hydralazine 75 mg and isosorbide dinitrate 40 mg 3 times a day, increasing every 1–2 weeks.
• Metoprolol succinate (long-acting, oral): Start at 25 mg once daily in NYHA II, 12.5 mg once daily in more severe heart failure; If tolerated, double the dose every 2 weeks to a maximum of 200 mg once a day.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Contraception: use a progestin implant or levonorgestrel-releasing intrauterine device.

Note

• If pregnancy is planned, discontinue ACE inhibitors, ARBs and ARNIs before conception.
• Avoid spironolactone.
• Combined oral contraceptive is strictly contraindicated.
• Maintain beta blocker therapy; Avoid atenolol.
• Metoprolol succinate (long-acting, oral): Started only in stable and euvolemic patients; It is not started new in acute decompensated heart failure; In symptomatic bradycardia, the dose is reduced.
• Bisoprolol: Started only in stable and euvolemic patients.

Approach

1. Risk class: mWHO IV; The risk of relapse can reach 50% and maternal mortality can reach 15–20%.
2. Discuss the option of terminating the pregnancy if it is legally and ethically appropriate; Make the decision jointly with the woman.
3. If pregnancy persists, continue care with the Pregnancy Heart Team at a tertiary or quaternary center with advanced cardiac, obstetrics, anesthesia, intensive care and neonatal expertise.
4. Monitor ventricular function with echocardiography, individualizing follow-up frequency according to symptoms, functional status, and ventricular function; watch for red flags (paroxysmal nocturnal dyspnea, persistent cough, chest pain, marked tachycardia, jugular venous distention, basal rales, S3 gallop), and measure BNP/NT-proBNP when in doubt.
5. Prepare a written birth plan with the Pregnancy Heart Team by approximately week 32.
6. Vaginal delivery is recommended for most cardiomyopathies; Caesarean section is preferred if there is obstetric indication, severe heart failure (LVEF < 30% and/or NYHA III–IV), uncontrolled arrhythmia, outflow tract obstruction ≥ 50 mmHg in HCM, or labor under VKA (warfarin).
7. Initiate epidural analgesia early in labor and maintain it rigorously; It reduces systemic vascular resistance and provides an advantage in left ventricular systolic dysfunction.
8. Use assisted vaginal birth in conjunction with cardiology according to individual risk assessment to shorten the second stage.
9. Monitor fetal growth with serial USG and fetal well-being with umbilical artery and middle cerebral artery (MCA) Doppler.
10. If the fetus has reached viability, perform intermittent or continuous fetal heart rate monitoring during hospitalization for maternal decompensation according to gestational age and clinical status; monitor continuously during anesthesia administration, labor, and delivery. Do not delay maternal stabilization for fetal assessment.
11. Closely monitor the first 24–72 hours after birth as the most critical period.
12. If acute pulmonary edema or hypoperfusion develops, switch to an acute decompensated heart failure approach.
13. Recommend tubal ligation before discharge.
14. If anticoagulation is administered, plan discontinuation of heparin before planned delivery according to dose and risk of thrombosis (for neuroaxial intervention, at least 12 hours should elapse from the last prophylactic LMWH dose and at least 24 hours from the intermediate or therapeutic dose); plan postpartum resumption time if indication persists and there is no significant bleeding or significant risk of bleeding (general obstetric range 4–6 hours after vaginal birth, 6–12 hours after cesarean section).
15. Write the indication for anticoagulation and the end/reassessment date in the discharge plan: If anticoagulation is administered due to LVEF < 35%, continue for at least 6 weeks postpartum and reassess based on LVEF; If bromocriptine is used, maintain at least a prophylactic dose of LMWH throughout treatment; In case of intracardiac thrombus, embolism or permanent indication, the expert team determines the duration.

Treatment

• Metoprolol succinate (long-acting, oral): Start at 25 mg once daily in NYHA II, 12.5 mg once daily in more severe heart failure; If tolerated, double the dose every 2 weeks to a maximum of 200 mg once a day.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Hydralazine + isosorbide dinitrate (oral): start with hydralazine 25–37.5 mg and isosorbide dinitrate 20 mg 3 times daily; Target hydralazine 75 mg and isosorbide dinitrate 40 mg 3 times a day, increasing every 1–2 weeks.
• If IV nitrate is required — Nitroglycerin: Start with 5 µg/min IV infusion, increasing every 3–5 minutes to a maximum of 100 µg/min; It is given together with a diuretic.
• If congestion develops — Furosemide (oral): 20–40 mg once daily is started; If the response is insufficient, the single dose is adjusted by doubling instead of giving the same dose more frequently; The new dose is given no earlier than 6–8 hours after the previous dose; usual dose 40–240 mg per day; Maximum total daily dose of 600 mg (up to 1000 mg in severe renal impairment).
• After birth, in hemodynamically stable patient — Enalapril: 2.5 mg twice daily is started; The target is 10–20 mg twice a day, doubling the dose every 1–2 weeks.
• If documented intracardiac thrombus or LVEF < 35%, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• In other cases, if thromboprophylaxis is to be applied by individual decision — Enoxaparin (prophylactic): 40 mg SC once a day under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance < 30 mL/min, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH during pregnancy — UFH (SC, prophylactic): 5000–7500 IU in the 1st trimester, 7500–10 000 IU in the 2nd trimester, 10 000 IU SC every 12 hours in the 3rd trimester (dose is reduced if aPTT is prolonged).
• If creatinine clearance is < 30 mL/min, instead of postpartum prophylactic LMWH — UFH (SC, prophylactic): postpartum 5000 IU SC every 8–12 hours.
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• ACE inhibitor, ARB and ARNI are contraindicated in pregnancy; If using it, stop it.
• Avoid spironolactone during pregnancy; Review current therapy due to possible antiandrogenic effects and limited pregnancy safety data.
• Use only cardioselective beta blockers (metoprolol, bisoprolol) during pregnancy.
• Monitor the newborn of a mother using beta blockers for bradycardia and hypoglycemia.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• Combined oral contraceptive is strictly contraindicated.
• If UFH is used, before neuraxial intervention: stop IV infusion at least 4–6 hours before; Wait 4–6 hours after SC 5000 IU (2–3 times a day), wait 12 hours after SC 7500–10 000 IU every 12 hours, wait 24 hours after single dose > 10 000 IU or total daily > 20 000 IU; In all cases, verify that coagulation (aPTT) is normal before intervention. Check platelet count if UFH has been used for more than 4 days.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Metoprolol succinate (long-acting, oral): Started only in stable and euvolemic patients; It is not started new in acute decompensated heart failure; In symptomatic bradycardia, the dose is reduced.
• Bisoprolol: Started only in stable and euvolemic patients.
• Nitroglycerin: Start if systolic BP is above 110 mmHg.
• Furosemide (oral): No breastfeeding difficulties have been reported with the low dose (20 mg/day) in breastfeeding.
• Furosemide (oral): Use with caution during pregnancy as excessive diuresis may reduce uterine blood flow and placental perfusion.
• Enalapril: Contraindicated in pregnancy; Can be used during breastfeeding. If serum sodium is <130 mEq/L or serum creatinine is >1.6 mg/dL, start with 2.5 mg once daily under close supervision; The dose is increased every 4 days at the earliest unless there is severe hypotension or significant deterioration of renal function.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Risk class: mWHO IV; Pregnancy is contraindicated, recommend avoiding pregnancy.
2. Explain in counseling that maternal mortality is 15–50%.
3. Address fetal effects, uncertainty of evidence, reproductive alternatives, and effective contraception in counseling with the expert multidisciplinary team.
4. Conduct reproductive planning with the Pregnancy Heart Team, which includes a perinatologist, cardiologist and geneticist.
5. Clearly state in the record that pregnancy is contraindicated, the rationale, and the patient's understanding and preferences.
6. Recommend tubal ligation; Share the decision without forcing it and evaluate the procedure and anesthesia risk in advance.

Treatment

• If the woman still plans pregnancy, instead of ACE inhibitor, ARB and ARNI — Hydralazine + isosorbide dinitrate (oral): start with hydralazine 25–37.5 mg and isosorbide dinitrate 20 mg 3 times daily; Target hydralazine 75 mg and isosorbide dinitrate 40 mg 3 times a day, increasing every 1–2 weeks.
• Metoprolol succinate (long-acting, oral): Start at 25 mg once daily in NYHA II, 12.5 mg once daily in more severe heart failure; If tolerated, double the dose every 2 weeks to a maximum of 200 mg once a day.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Contraception: use a progestin implant or levonorgestrel-releasing intrauterine device.

Note

• ACE inhibitor, ARB and ARNI are teratogenic; If the woman still plans the pregnancy, stop it.
• Optimize beta blocker therapy; Avoid atenolol.
• Avoid spironolactone if pregnancy is planned.
• Combined oral contraceptive is strictly contraindicated; It worsens heart failure through sodium and water retention and increases the risk of VTE.
• Metoprolol succinate (long-acting, oral): Started only in stable and euvolemic patients; It is not started new in acute decompensated heart failure; In symptomatic bradycardia, the dose is reduced.
• Bisoprolol: Started only in stable and euvolemic patients.

Approach

1. Risk class: mWHO IV; maternal mortality is 15–50%.
2. Recommend termination of pregnancy in the first trimester; Make the decision jointly with the woman within the legal and ethical framework.
3. If pregnancy persists, continue care with the Pregnancy Heart Team at a tertiary or quaternary center with advanced cardiac, obstetrics, anesthesia, intensive care and neonatal expertise.
4. Monitor ventricular function with ECHO, individualizing the frequency of checks according to symptoms, functional status and ventricular function; Monitor closely in early pregnancy as rapid decompensation may occur after discontinuation of an ACE inhibitor, ARB, or ARNI.
5. Prepare a written birth plan with the Pregnancy Heart Team by approximately week 32.
6. Vaginal delivery is recommended for most cardiomyopathies; Caesarean section is preferred if there is obstetric indication, severe heart failure (LVEF < 30% and/or NYHA III–IV), uncontrolled arrhythmia, outflow tract obstruction ≥ 50 mmHg in HCM, or labor under VKA (warfarin).
7. Initiate epidural analgesia early in labor and maintain it rigorously; It reduces systemic vascular resistance and provides an advantage in left ventricular systolic dysfunction.
8. Use assisted vaginal birth in conjunction with cardiology according to individual risk assessment to shorten the second stage.
9. Monitor fetal growth with serial USG and fetal well-being with umbilical artery and middle cerebral artery (MCA) Doppler.
10. If the fetus has reached viability, perform intermittent or continuous fetal heart rate monitoring during hospitalization for maternal decompensation according to gestational age and clinical status; monitor continuously during anesthesia administration, labor, and delivery. Do not delay maternal stabilization for fetal assessment.
11. Closely monitor the first 24–72 hours after birth as the most critical period; Intensify postpartum monitoring.
12. If acute pulmonary edema or hypoperfusion develops, switch to an acute decompensated heart failure approach.
13. Recommend tubal ligation before discharge.
14. If anticoagulation is administered, plan discontinuation of heparin before planned delivery according to dose and risk of thrombosis (for neuroaxial intervention, at least 12 hours should elapse from the last prophylactic LMWH dose and at least 24 hours from the intermediate or therapeutic dose); plan postpartum resumption time if indication persists and there is no significant bleeding or significant risk of bleeding (general obstetric range 4–6 hours after vaginal birth, 6–12 hours after cesarean section).
15. Write the indication for anticoagulation and the end/reassessment date in the discharge plan: If anticoagulation is administered due to LVEF < 35%, continue for at least 6 weeks postpartum and reassess based on LVEF; In case of intracardiac thrombus, embolism or permanent indication, the expert team determines the duration.

Treatment

• Hydralazine + isosorbide dinitrate (oral): start with hydralazine 25–37.5 mg and isosorbide dinitrate 20 mg 3 times daily; Target hydralazine 75 mg and isosorbide dinitrate 40 mg 3 times a day, increasing every 1–2 weeks.
• If congestion develops — Furosemide (oral): 20–40 mg once daily is started; If the response is insufficient, the single dose is adjusted by doubling instead of giving the same dose more frequently; The new dose is given no earlier than 6–8 hours after the previous dose; usual dose 40–240 mg per day; Maximum total daily dose of 600 mg (up to 1000 mg in severe renal impairment).
• After birth, in hemodynamically stable patient — Enalapril: 2.5 mg twice daily is started; The target is 10–20 mg twice a day, doubling the dose every 1–2 weeks.
• Metoprolol succinate (long-acting, oral): Start at 25 mg once daily in NYHA II, 12.5 mg once daily in more severe heart failure; If tolerated, double the dose every 2 weeks to a maximum of 200 mg once a day.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• If documented intracardiac thrombus or LVEF < 35%, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• In other cases, if thromboprophylaxis is to be applied by individual decision — Enoxaparin (prophylactic): 40 mg SC once a day under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance < 30 mL/min, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH during pregnancy — UFH (SC, prophylactic): 5000–7500 IU in the 1st trimester, 7500–10 000 IU in the 2nd trimester, 10 000 IU SC every 12 hours in the 3rd trimester (dose is reduced if aPTT is prolonged).
• If creatinine clearance is < 30 mL/min, instead of postpartum prophylactic LMWH — UFH (SC, prophylactic): postpartum 5000 IU SC every 8–12 hours.
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• ACE inhibitor, ARB and ARNI are contraindicated in pregnancy; If using it, stop it.
• Optimize beta blocker therapy; Avoid atenolol.
• Avoid spironolactone.
• Monitor the newborn of a mother using beta blockers for bradycardia and hypoglycemia.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• Combined oral contraceptive is strictly contraindicated.
• If UFH is used, before neuraxial intervention: stop IV infusion at least 4–6 hours before; Wait 4–6 hours after SC 5000 IU (2–3 times a day), wait 12 hours after SC 7500–10 000 IU every 12 hours, wait 24 hours after single dose > 10 000 IU or total daily > 20 000 IU; In all cases, verify that coagulation (aPTT) is normal before intervention. Check platelet count if UFH has been used for more than 4 days.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Furosemide (oral): No breastfeeding difficulties have been reported with the low dose (20 mg/day) in breastfeeding.
• Furosemide (oral): Use with caution during pregnancy as excessive diuresis may reduce uterine blood flow and placental perfusion.
• Enalapril: Contraindicated in pregnancy; Can be used during breastfeeding. If serum sodium is <130 mEq/L or serum creatinine is >1.6 mg/dL, start with 2.5 mg once daily under close supervision; The dose is increased every 4 days at the earliest unless there is severe hypotension or significant deterioration of renal function.
• Metoprolol succinate (long-acting, oral): Started only in stable and euvolemic patients; It is not started new in acute decompensated heart failure; In symptomatic bradycardia, the dose is reduced.
• Bisoprolol: Started only in stable and euvolemic patients.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Risk class: mWHO III if LVEF 30–45%, mWHO II–III if LVEF > 45%.
2. If LVEF is 30–45%, close ECHO monitoring is required at the reference center during pregnancy.
3. Explain that a stable woman with LVEF > 40% and NYHA I–II usually tolerates pregnancy.
4. Explain that even in moderate dysfunction, clinically significant heart failure, arrhythmia, or medication increase may be required.
5. Conduct pregnancy planning with the Pregnancy Heart Team, which includes a perinatologist, cardiologist and geneticist.
6. Document NYHA class, ECG, ECHO and baseline BNP/NT‑proBNP before pregnancy; Perform a stress test on the selected patient.
7. Plan pregnancy while clinically stable, at optimal functional capacity, and on a pregnancy-compatible medication regimen; Make medication changes before pregnancy and verify stability on the new regimen.
8. If assisted reproductive technology is planned, make the decision with the reproductive medicine specialist and the Pregnancy Heart Team before treatment; If possible, recommend single embryo transfer.

Treatment

• Instead of ACE inhibitor, ARB, or ARNI — Hydralazine + isosorbide dinitrate (oral): start with hydralazine 25–37.5 mg and isosorbide dinitrate 20 mg 3 times daily; Target hydralazine 75 mg and isosorbide dinitrate 40 mg 3 times a day, increasing every 1–2 weeks.
• Metoprolol succinate (long-acting, oral): Start at 25 mg once daily in NYHA II, 12.5 mg once daily in more severe heart failure; If tolerated, double the dose every 2 weeks to a maximum of 200 mg once a day.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Effective contraception: use a progestin implant or levonorgestrel-releasing intrauterine device until pregnancy is planned.

Note

• Discontinue ACE inhibitor, ARB, and ARNI when pregnancy is planned due to teratogenicity.
• Optimize beta blocker therapy; Avoid atenolol.
• Avoid spironolactone.
• Combined oral contraceptive is contraindicated.
• Metoprolol succinate (long-acting, oral): Started only in stable and euvolemic patients; It is not started new in acute decompensated heart failure; In symptomatic bradycardia, the dose is reduced.
• Bisoprolol: Started only in stable and euvolemic patients.

Approach

1. Risk class: mWHO III if LVEF 30–45%, mWHO II–III if LVEF > 45%.
2. Watch with the Pregnancy Heart Team; If LVEF is 30–45%, perform close ECHO monitoring at the reference center.
3. Stable women with LVEF > 40% and NYHA I–II usually tolerate pregnancy.
4. Monitor closely in early pregnancy as rapid decompensation may occur after discontinuation of an ACE inhibitor, ARB, or ARNI.
5. Prepare a written birth plan with the Pregnancy Heart Team by approximately week 32.
6. Vaginal delivery is recommended for most cardiomyopathies; Caesarean section is preferred if there is obstetric indication, severe heart failure (LVEF < 30% and/or NYHA III–IV), uncontrolled arrhythmia, outflow tract obstruction ≥ 50 mmHg in HCM, or labor under VKA (warfarin).
7. Initiate epidural analgesia early in labor and maintain it rigorously; It reduces systemic vascular resistance and provides an advantage in left ventricular systolic dysfunction.
8. Use assisted vaginal birth in conjunction with cardiology according to individual risk assessment to shorten the second stage.
9. Monitor fetal growth with serial USG and fetal well-being with umbilical artery and middle cerebral artery (MCA) Doppler.
10. If the fetus has reached viability, perform intermittent or continuous fetal heart rate monitoring during hospitalization for maternal decompensation according to gestational age and clinical status; monitor continuously during anesthesia administration, labor, and delivery. Do not delay maternal stabilization for fetal assessment.
11. Closely monitor the first 24–72 hours after birth as the most critical period; Intensify postpartum monitoring.
12. If acute pulmonary edema or hypoperfusion develops, switch to an acute decompensated heart failure approach.
13. If anticoagulation is administered, plan discontinuation of heparin before planned delivery according to dose and risk of thrombosis (for neuroaxial intervention, at least 12 hours should elapse from the last prophylactic LMWH dose and at least 24 hours from the intermediate or therapeutic dose); plan postpartum resumption time if indication persists and there is no significant bleeding or significant risk of bleeding (general obstetric range 4–6 hours after vaginal birth, 6–12 hours after cesarean section).
14. Write the indication for anticoagulation and the end/reassessment date in the discharge plan: If anticoagulation is administered due to LVEF < 35%, continue for at least 6 weeks postpartum and reassess based on LVEF; In case of intracardiac thrombus, embolism or permanent indication, the expert team determines the duration.

Treatment

• Hydralazine + isosorbide dinitrate (oral): start with hydralazine 25–37.5 mg and isosorbide dinitrate 20 mg 3 times daily; Target hydralazine 75 mg and isosorbide dinitrate 40 mg 3 times a day, increasing every 1–2 weeks.
• If congestion develops — Furosemide (oral): 20–40 mg once daily is started; If the response is insufficient, the single dose is adjusted by doubling instead of giving the same dose more frequently; The new dose is given no earlier than 6–8 hours after the previous dose; usual dose 40–240 mg per day; Maximum total daily dose of 600 mg (up to 1000 mg in severe renal impairment).
• After birth, in hemodynamically stable patient — Enalapril: 2.5 mg twice daily is started; The target is 10–20 mg twice a day, doubling the dose every 1–2 weeks.
• Metoprolol succinate (long-acting, oral): Start at 25 mg once daily in NYHA II, 12.5 mg once daily in more severe heart failure; If tolerated, double the dose every 2 weeks to a maximum of 200 mg once a day.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• If documented intracardiac thrombus or LVEF < 35%, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• In other cases, if thromboprophylaxis is to be applied by individual decision — Enoxaparin (prophylactic): 40 mg SC once a day under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance < 30 mL/min, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH during pregnancy — UFH (SC, prophylactic): 5000–7500 IU in the 1st trimester, 7500–10 000 IU in the 2nd trimester, 10 000 IU SC every 12 hours in the 3rd trimester (dose is reduced if aPTT is prolonged).
• If creatinine clearance is < 30 mL/min, instead of postpartum prophylactic LMWH — UFH (SC, prophylactic): postpartum 5000 IU SC every 8–12 hours.
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• ACE inhibitor, ARB and ARNI are contraindicated in pregnancy; If using it, stop it.
• Optimize beta blocker therapy; Avoid atenolol.
• Avoid spironolactone.
• Monitor the newborn of a mother using beta blockers for bradycardia and hypoglycemia.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• Combined oral contraceptive is strictly contraindicated.
• If UFH is used, before neuraxial intervention: stop IV infusion at least 4–6 hours before; Wait 4–6 hours after SC 5000 IU (2–3 times a day), wait 12 hours after SC 7500–10 000 IU every 12 hours, wait 24 hours after single dose > 10 000 IU or total daily > 20 000 IU; In all cases, verify that coagulation (aPTT) is normal before intervention. Check platelet count if UFH has been used for more than 4 days.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Furosemide (oral): No breastfeeding difficulties have been reported with the low dose (20 mg/day) in breastfeeding.
• Furosemide (oral): Use with caution during pregnancy as excessive diuresis may reduce uterine blood flow and placental perfusion.
• Enalapril: Contraindicated in pregnancy; Can be used during breastfeeding. If serum sodium is <130 mEq/L or serum creatinine is >1.6 mg/dL, start with 2.5 mg once daily under close supervision; The dose is increased every 4 days at the earliest unless there is severe hypotension or significant deterioration of renal function.
• Metoprolol succinate (long-acting, oral): Started only in stable and euvolemic patients; It is not started new in acute decompensated heart failure; In symptomatic bradycardia, the dose is reduced.
• Bisoprolol: Started only in stable and euvolemic patients.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Risk class: mWHO IV (symptomatic severe outflow tract obstruction ≥ 50 mmHg or severe symptomatic left ventricular dysfunction, LVEF < 50%); pregnancy is not recommended, recommend avoiding pregnancy.
2. Discuss maternal risk, fetal effects, uncertainty of evidence, reproductive alternatives, and effective contraception in counseling with an expert multidisciplinary team.
3. Assess symptoms, family history of sudden cardiac death, history of arrhythmia, ventricular function, left ventricular outflow tract (LVOT) gradient, and medications used.
4. Conduct reproductive planning with the Pregnancy Heart Team, which includes a perinatologist, cardiologist and geneticist; The disease is inherited in an autosomal dominant manner.
5. Clearly state in the record that pregnancy is contraindicated, the rationale, and the patient's understanding and preferences.
6. Recommend tubal ligation; Share the decision without forcing it and evaluate the procedure and anesthesia risk in advance.

Treatment

• Metoprolol (oral): immediate-release tartrate starts at 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Contraception: use a progestin implant or levonorgestrel-releasing intrauterine device.

Note

• Maintain beta blocker therapy as baseline therapy.
• Avoid positive inotropes such as digoxin, dobutamine, and milrinone if left ventricular outflow tract obstruction is present (at rest or with provocation); They increase the outflow tract gradient.
• Avoid excessive diuresis and vasodilation leading to hypovolemia.
• Combined oral contraceptive is strictly contraindicated.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Bisoprolol: Started only in stable and euvolemic patients.

Approach

1. Risk class: mWHO IV (symptomatic severe outflow tract obstruction ≥ 50 mmHg or severe symptomatic left ventricular dysfunction, LVEF < 50%); Discuss the risk to the mother in early counseling, continuation in a specialist center and the option of termination if legally and ethically appropriate.
2. If pregnancy persists, continue care with the Pregnancy Heart Team at a tertiary or quaternary center with advanced cardiac, obstetrics, anesthesia, intensive care and neonatal expertise.
3. Protect against hypovolemia (bleeding, excessive diuresis), vasodilation and tachycardia; These can suddenly worsen the obstruction and lead to syncope or fatal cardiogenic shock.
4. Prepare a written birth plan with the Pregnancy Heart Team by approximately week 32.
5. Vaginal delivery is recommended for most cardiomyopathies; Caesarean section is preferred if there is obstetric indication, severe heart failure (LVEF < 30% and/or NYHA III–IV), uncontrolled arrhythmia, outflow tract obstruction ≥ 50 mmHg in HCM, or labor under VKA (warfarin).
6. Avoid excessive vasodilation in epidural analgesia.
7. Use assisted vaginal birth in conjunction with cardiology according to individual risk assessment to shorten the second stage.
8. Monitor fetal growth with serial USG and fetal well-being with umbilical artery and middle cerebral artery (MCA) Doppler.
9. Closely monitor the first 24–72 hours after birth as the most critical period.
10. Recommend tubal ligation before discharge.

Treatment

• Metoprolol (oral): immediate-release tartrate starts at 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• Maintain beta-blocker therapy as baseline therapy; Avoid atenolol.
• Avoid positive inotropes such as digoxin, dobutamine, and milrinone if left ventricular outflow tract obstruction is present (at rest or with provocation); They increase the outflow tract gradient.
• Monitor the newborn of a mother using beta blockers for bradycardia and hypoglycemia.
• Combined oral contraceptive is strictly contraindicated.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Bisoprolol: Started only in stable and euvolemic patients.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Risk class: mWHO II–III in uncomplicated HCM; mWHO III if arrhythmic and/or moderate hemodynamic complications are present. Pregnancy is usually well tolerated when symptoms are mild and systolic function is preserved.
2. Indicate in counseling that significant left ventricular outflow tract (LVOT) obstruction, previous syncope, arrhythmia, heart failure symptoms, or impaired systolic function increases risk.
3. Assess symptoms, family history of sudden cardiac death, history of arrhythmia, ventricular function, outflow tract gradient, and medications used.
4. Conduct pregnancy planning with the Pregnancy Heart Team, which includes a perinatologist, cardiologist and geneticist; The disease is inherited in an autosomal dominant manner.
5. Document NYHA class, ECG, ECHO and baseline BNP/NT‑proBNP before pregnancy; Perform a stress test on the selected patient.
6. Explain that increased preload during pregnancy often relieves obstruction, but hypovolemia, vasodilation, and tachycardia can lead to sudden worsening.

Treatment

• Metoprolol (oral): immediate-release tartrate starts at 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Effective contraception: use a progestin implant or levonorgestrel-releasing intrauterine device until pregnancy is planned.

Note

• Maintain beta-blocker therapy as baseline therapy; Avoid atenolol.
• Avoid positive inotropes such as digoxin, dobutamine, and milrinone if left ventricular outflow tract obstruction is present (at rest or with provocation); They increase the outflow tract gradient.
• Avoid excessive diuresis and vasodilation leading to hypovolemia.
• Combined oral contraceptive is contraindicated.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Bisoprolol: Started only in stable and euvolemic patients.

Approach

1. Risk class: mWHO II–III in uncomplicated HCM, mWHO III with arrhythmic and/or moderate hemodynamic complications; follow with the Pregnancy Heart Team and perform close echocardiographic surveillance at a referral center.
2. Protect against hypovolemia (bleeding, excessive diuresis), vasodilation and tachycardia; These can suddenly worsen the obstruction and lead to syncope or fatal cardiogenic shock.
3. Prepare a written birth plan with the Pregnancy Heart Team by approximately week 32.
4. Vaginal delivery is recommended for most cardiomyopathies; Caesarean section is preferred if there is obstetric indication, severe heart failure (LVEF < 30% and/or NYHA III–IV), uncontrolled arrhythmia, outflow tract obstruction ≥ 50 mmHg in HCM, or labor under VKA (warfarin).
5. Initiate epidural analgesia early in labor and maintain it rigorously; Avoid excessive vasodilation.
6. Use assisted vaginal birth in conjunction with cardiology according to individual risk assessment to shorten the second stage.
7. Monitor fetal growth with serial USG and fetal well-being with umbilical artery and middle cerebral artery (MCA) Doppler.
8. Closely monitor the first 24–72 hours after birth as the most critical period.

Treatment

• Metoprolol (oral): immediate-release tartrate starts at 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• Maintain beta-blocker therapy as baseline therapy; Avoid atenolol.
• Avoid positive inotropes such as digoxin, dobutamine, and milrinone if left ventricular outflow tract obstruction is present (at rest or with provocation); They increase the outflow tract gradient.
• Monitor the newborn of a mother using beta blockers for bradycardia and hypoglycemia.
• Combined oral contraceptive is strictly contraindicated.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Bisoprolol: Started only in stable and euvolemic patients.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Assess ventricular function and NYHA class even in the absence of active arrhythmia; If LVEF < 30% or NYHA III–IV, consider mWHO IV and recommend avoiding pregnancy; If there are no mWHO IV criteria, low-risk ARVC with genotype positive and no or mild phenotype is considered mWHO II–III, and moderate or severe ARVC is considered mWHO III.
2. The main risk is fatal ventricular arrhythmia; Explain in counseling that the volume load of pregnancy may trigger right heart failure and arrhythmic storm.
3. Conduct pregnancy planning with the Pregnancy Heart Team, which includes a perinatologist, cardiologist and geneticist.
4. Assess ventricular function, ischemic disease, hereditary channelopathies, and family history of sudden cardiac death; Request electrophysiology consultation if necessary.
5. Perform baseline ECG and ECHO; If ECHO is inadequate, use non-contrast cardiac MRI for right ventricular morphology.
6. Provide arrhythmia control before pregnancy if it can be safely improved.
7. ICD indications do not change with pregnancy; Plan for appropriate reprogramming of the ICD during pregnancy.

Treatment

• Metoprolol (oral): immediate-release tartrate starts at 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• If sotalol has been used before or if antiarrhythmic treatment is required, with the decision of the expert team, instead of metoprolol/bisoprolol — Sotalol: 80 mg is started by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.
• Effective contraception: use a progestin implant or levonorgestrel-releasing intrauterine device until pregnancy is planned.

Note

• Maintain beta blocker therapy, including sotalol.
• Avoid amiodarone; Use only in life-threatening arrhythmias.
• Combined oral contraceptive is contraindicated.
• Sotalol is used with caution in low ejection fraction; Fetal growth is monitored due to the beta blocker effect; It is not given with another beta blocker.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Bisoprolol: Started only in stable and euvolemic patients.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.

Approach

1. Assess ventricular function and NYHA class even in the absence of active arrhythmia; If LVEF < 30% or NYHA III–IV, accept mWHO IV and seek early risk and pregnancy options counseling with specialist Pregnancy Heart Team; If there are no mWHO IV criteria, low-risk ARVC with genotype positive and no or mild phenotype is considered mWHO II–III, and moderate or severe ARVC is considered mWHO III.
2. Follow closely with the Pregnancy Heart Team, which is run jointly by cardiology and obstetrics at the Tertiary center; Perform regular ECG/Holter, monitor for signs of right heart failure and arrhythmic storm.
3. Prepare a written antenatal emergency plan; Determine the birth plan, intrapartum emergency algorithm and team roles in writing by approximately the 32nd week.
4. Vaginal delivery is recommended for most cardiomyopathies; Caesarean section is preferred if there is obstetric indication, severe heart failure (LVEF < 30% and/or NYHA III–IV), uncontrolled arrhythmia, outflow tract obstruction ≥ 50 mmHg in HCM, or labor under VKA (warfarin).
5. Initiate epidural analgesia early in labor and maintain it meticulously.
6. Use assisted vaginal birth in conjunction with cardiology according to individual risk assessment to shorten the second stage.
7. Monitor fetal growth with serial USG and fetal well-being with umbilical artery and middle cerebral artery (MCA) Doppler.
8. Intensify monitoring during puerperium: plan early check-up before discharge, teach warning symptoms, and review compatibility of antiarrhythmic therapy with breast-feeding.

Treatment

• Metoprolol (oral): immediate-release tartrate starts at 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• If sotalol has been used before or if antiarrhythmic treatment is required, with the decision of the expert team, instead of metoprolol/bisoprolol — Sotalol: 80 mg is started by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.
• Reprogram ICD appropriately.
• Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• Do not discontinue beta blocker treatment, including sotalol, throughout pregnancy and the postpartum period.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Monitor the newborn of a mother using beta blockers for bradycardia and hypoglycemia.
• Combined oral contraceptive is strictly contraindicated.
• Sotalol is used with caution in low ejection fraction; Fetal growth is monitored due to the beta blocker effect; It is not given with another beta blocker.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Bisoprolol: Started only in stable and euvolemic patients.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Start treatment and ensure maternal stabilization without waiting for detailed rhythm classification.
2. Quickly restore maternal circulation; this is the strongest modifiable predictor of fetal outcome.
3. After stabilization, evaluate electrolytes, thyroid function, complete blood count, and ECHO.
4. Refer to tertiary center and multidisciplinary committee.
5. Conduct maternal rhythm therapy in conjunction with fetal monitoring.
6. Prepare the birth and postpartum follow-up plan in writing.
7. Schedule early follow-up prior to discharge, teach warning symptoms of arrhythmia recurrence, and review compatibility of antiarrhythmic therapy with breast-feeding.

Treatment

• In VT with a pulse — Synchronized electrical cardioversion: initial energy on the biphasic device is 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• In pulseless VT or VF — Defibrillation: manufacturer's recommended energy on a biphasic device (initial 120–200 J), highest device energy if unknown; subsequent shocks with the same or higher energy; 360 J in monophasic device; The pads are placed anterolaterally, and the lateral pad is placed under or next to the breast tissue.
• In life-threatening refractory arrhythmia — Amiodarone: 150 mg IV over 10 minutes (may be repeated if arrhythmia recurs); followed by 1 mg/min IV infusion for 6 hours, then 0.5 mg/min for 18 hours; 300 mg IV/IO bolus in cardiac arrest, second dose 150 mg if necessary.
• Reprogram ICD appropriately.
• Catheter ablation: perform in refractory arrhythmia in an experienced center with individual risk-benefit evaluation.

Note

• Pregnancy week is not a reason to postpone cardioversion or defibrillation.
• Maintain beta blocker therapy; If sotalol is used, carry out under specialist supervision and with close ECG monitoring; Reconsider sotalol if cardiogenic shock or decompensated heart failure develops.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Defibrillation: During pregnancy, the energy is the same as in non-pregnancy; if the fundus is at or above the umbilicus, manual left lateral uterine displacement is performed with chest compressions; Once cardiac arrest is diagnosed, external and internal fetal monitors are removed; Resuscitation and shock are not delayed for fetal assessment, fetal monitoring, or removal of monitors.
• Amiodarone: Avoided during pregnancy due to risk of fetal adverse effects; It is used only in life-threatening arrhythmia that cannot be controlled with other treatments; If administered, the fetus is monitored for bradycardia, growth restriction, and thyroid function.

Approach

1. Obtain a 12-lead ECG, perform rhythm monitoring if necessary; Request electrolytes, thyroid function, complete blood count and ECHO.
2. Assess for triggers and concomitant structural heart disease.
3. Refer to tertiary center and multidisciplinary committee.
4. Conduct maternal rhythm therapy in conjunction with fetal monitoring.
5. Prepare the birth and postpartum follow-up plan in writing.
6. Schedule early follow-up prior to discharge, teach warning symptoms of arrhythmia recurrence, and review compatibility of antiarrhythmic therapy with breast-feeding.

Treatment

• Regardless of hemodynamic status in sustained VT (without waiting if drug conversion has been attempted and the drug is ineffective or contraindicated) — Synchronized electrical cardioversion: initial energy on the biphasic device is 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• Lidocaine: 1–1.5 mg/kg IV bolus at 25–50 mg/min; additional bolus of 0.5–0.75 mg/kg every 5–10 minutes if necessary; Cumulative dose in one hour is up to 3 mg/kg and 300 mg; maintenance 1–4 mg/min IV infusion.
• Procainamide: 15 mg/kg IV loading over at least 30 minutes and the infusion rate not to exceed 50 mg/min (total loading not more than 17 mg/kg); followed by 1–4 mg/min IV infusion.
• In life-threatening refractory arrhythmia — Amiodarone: 150 mg IV over 10 minutes (may be repeated if arrhythmia recurs); followed by 1 mg/min IV infusion for 6 hours, then 0.5 mg/min for 18 hours; 300 mg IV/IO bolus in cardiac arrest, second dose 150 mg if necessary.
• If pulseless VT or VF develops — Defibrillation: manufacturer's recommended energy on a biphasic device (initial 120–200 J), if unknown, highest energy of the device; subsequent shocks with the same or higher energy; 360 J in monophasic device; The pads are placed anterolaterally, and the lateral pad is placed under or next to the breast tissue.
• Reprogram ICD appropriately.
• Catheter ablation: perform in refractory arrhythmia in an experienced center with individual risk-benefit evaluation.

Note

• Maintain beta blocker therapy; If sotalol is used, carry out under specialist supervision and with close ECG monitoring; Reconsider sotalol if cardiogenic shock or decompensated heart failure develops.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Lidocaine: All lidocaine doses, including lidocaine given for regional anesthesia, are included in the total dose.
• Procainamide: Stop loading if arrhythmia is suppressed, hypotension develops, or QRS duration is prolonged by more than 50%; It is avoided in prolonged QT and heart failure.
• Procainamide: Uterine irritability and preterm labor have been reported with IV use during pregnancy.
• Amiodarone: Avoided during pregnancy due to risk of fetal adverse effects; It is used only in life-threatening arrhythmia that cannot be controlled with other treatments; If administered, the fetus is monitored for bradycardia, growth restriction, and thyroid function.
• Defibrillation: During pregnancy, the energy is the same as in non-pregnancy; if the fundus is at or above the umbilicus, manual left lateral uterine displacement is performed with chest compressions; Once cardiac arrest is diagnosed, external and internal fetal monitors are removed; Resuscitation and shock are not delayed for fetal assessment, fetal monitoring, or removal of monitors.

Approach

1. In case of signs of heart failure (increased jugular venous pressure, lung rales, dyspnea at rest, orthopnea, marked edema, hepatomegaly, oxygen desaturation), perform urgent cardiovascular evaluation and refer to the Pregnancy Heart Team.
2. Evaluate ventricular function and heart failure by ECHO; LVEF < 45% supports the diagnosis of peripartum cardiomyopathy.
3. If the suspicion of pulmonary embolism persists, do not terminate the evaluation with the ECHO result; Pursue appropriate V/Q scintigraphy or CT pulmonary angiography based on chest radiography and clinical evaluation.
4. Measure BNP/NT‑proBNP and troponin; BNP/NT‑proBNP is usually within the normal range in normal pregnancy and significant elevation supports heart failure, whereas elevated troponin is associated with poor prognosis.
5. Vaginal delivery is recommended for most cardiomyopathies; Caesarean section is preferred if there is obstetric indication, severe heart failure (LVEF < 30% and/or NYHA III–IV), uncontrolled arrhythmia, outflow tract obstruction ≥ 50 mmHg in HCM, or labor under VKA (warfarin).
6. Monitor fetal growth with serial USG and fetal well-being with umbilical artery and middle cerebral artery (MCA) Doppler.
7. If the fetus has reached viability, perform intermittent or continuous fetal heart rate monitoring during hospitalization for maternal decompensation according to gestational age and clinical status; monitor continuously during anesthesia administration, labor, and delivery. Do not delay maternal stabilization for fetal assessment.
8. Closely monitor the first 24–72 hours after birth as the most critical period.
9. Individually evaluate the need for anticoagulation if there is significant low LVEF, atrial arrhythmia, or ventricular thrombus in other cardiomyopathies.
10. Plan discontinuation of heparin before planned delivery based on dose and risk of thrombosis; for neuraxial intervention, at least 12 hours must elapse after the last prophylactic dose of LMWH and at least 24 hours after the intermediate or therapeutic dose; plan postpartum resumption time if indication persists and there is no significant bleeding or significant risk of bleeding (general obstetric range 4–6 hours after vaginal birth, 6–12 hours after cesarean section).

Treatment

• In Hypoxemia — Oxygen: Oxygen is administered if SpO2 is below 90% or PaO2 is below 60 mmHg; SpO2 is maintained at least 90%, preferably 95% or above; If SpO2 remains below 95% despite oxygen or respiratory distress (respiratory rate >25/min) persists, noninvasive positive pressure ventilation is applied; Intubation and invasive ventilation are applied in progressive respiratory failure despite oxygen or noninvasive support.
• Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in patients who have not used diuretics before; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• In congestion and adequate blood pressure — Nitroglycerin: Start with 5 µg/min IV infusion, increasing every 3–5 minutes to a maximum of 100 µg/min; It is given together with a diuretic.
• Hydralazine + isosorbide dinitrate (oral): start with hydralazine 25–37.5 mg and isosorbide dinitrate 20 mg 3 times daily; Target hydralazine 75 mg and isosorbide dinitrate 40 mg 3 times a day, increasing every 1–2 weeks.
• In PPCM with LVEF < 35% or intracardiac thrombus, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• If therapeutic anticoagulation is not applied and thromboprophylaxis is indicated (inpatient) — Enoxaparin (prophylactic): 40 mg SC once a day for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance < 30 mL/min, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH — UFH (SC, prophylactic): 5000–7500 IU in the 1st trimester, 7500–10 000 IU in the 2nd trimester, 10 000 IU SC every 12 hours in the 3rd trimester (dose is reduced if aPTT is prolonged).
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).

Note

• ACE inhibitor, ARB and ARNI are contraindicated during pregnancy.
• Avoid spironolactone during pregnancy; Review current therapy due to possible antiandrogenic effects and limited pregnancy safety data.
• Do not administer vasodilators in hypotension or cardiogenic shock.
• Avoid vasodilation and excessive diuresis leading to hypovolemia in hypertrophic cardiomyopathy; these can suddenly worsen outflow tract obstruction.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• If UFH is used, before neuraxial intervention: stop IV infusion at least 4–6 hours before; Wait 4–6 hours after SC 5000 IU (2–3 times a day), wait 12 hours after SC 7500–10 000 IU every 12 hours, wait 24 hours after single dose > 10 000 IU or total daily > 20 000 IU; In all cases, verify that coagulation (aPTT) is normal before intervention. Check platelet count if UFH has been used for more than 4 days.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Furosemide (IV): Since excessive diuresis during pregnancy may reduce uterine blood flow and placental perfusion, it is used with caution and the dose is titrated only in cases of pulmonary congestion or volume overload.
• Nitroglycerin: Start if systolic BP is above 110 mmHg.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. In case of signs of heart failure (increased jugular venous pressure, lung rales, dyspnea at rest, orthopnea, marked edema, hepatomegaly, oxygen desaturation), perform urgent cardiovascular evaluation and refer to the Pregnancy Heart Team.
2. Evaluate ventricular function and heart failure by ECHO; LVEF < 45% supports the diagnosis of peripartum cardiomyopathy.
3. If the suspicion of pulmonary embolism persists, do not terminate the evaluation with the ECHO result; Pursue appropriate V/Q scintigraphy or CT pulmonary angiography based on chest radiography and clinical evaluation.
4. Measure BNP/NT‑proBNP and troponin; Significant elevation of BNP/NT‑proBNP supports heart failure, elevation of troponin is associated with poor prognosis.
5. Closely monitor the first 24–72 hours after birth as the most critical period.
6. Individually evaluate the need for anticoagulation if there is significant low LVEF, atrial arrhythmia, or ventricular thrombus in other cardiomyopathies.
7. If anticoagulation remains indicated and there is no significant bleeding or significant risk of bleeding, plan for postpartum resumption; The general obstetric range is 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
8. Write the indication for anticoagulation and the end/reassessment date in the discharge plan: If anticoagulation is administered due to LVEF < 35%, continue for at least 6 weeks postpartum and reassess based on LVEF; If bromocriptine is used, maintain at least a prophylactic dose of LMWH throughout treatment; In case of intracardiac thrombus, embolism or permanent indication, the expert team determines the duration.

Treatment

• In Hypoxemia — Oxygen: Oxygen is administered if SpO2 is below 90% or PaO2 is below 60 mmHg; SpO2 is maintained at least 90%, preferably 95% or above; If SpO2 remains below 95% despite oxygen or respiratory distress (respiratory rate >25/min) persists, noninvasive positive pressure ventilation is applied; Intubation and invasive ventilation are applied in progressive respiratory failure despite oxygen or noninvasive support.
• Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in patients who have not used diuretics before; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• In congestion and adequate blood pressure — Nitroglycerin: Start with 5 µg/min IV infusion, increasing every 3–5 minutes to a maximum of 100 µg/min; It is given together with a diuretic.
• If there is left ventricular systolic dysfunction (low LVEF), regardless of the cause, after birth in the hemodynamically stable patient — Enalapril: 2.5 mg twice daily is started; The target is 10–20 mg twice a day, doubling the dose every 1–2 weeks.
• Bromocriptine may be considered if PPCM is the cause: if LVEF < 30%, 2.5 mg twice daily for 2 weeks, then 2.5 mg once daily for 6 weeks; If LVEF > 30%, 2.5 mg once daily for 1 week; Use at least prophylactic dose of LMWH together.
• In PPCM with LVEF < 35% or intracardiac thrombus, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours; If bromocriptine is used, add at least a prophylactic dose of LMWH.
• If therapeutic anticoagulation is not applied and thromboprophylaxis is indicated (inpatient, bromocriptine use) — Enoxaparin (prophylactic): 40 mg SC once a day for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance < 30 mL/min, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH — UFH (SC, prophylactic): 5000 IU SC every 8–12 hours after birth.
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• If bromocriptine is started in peripartum cardiomyopathy, breastfeeding cannot be continued during treatment; Discuss the baby's feeding plan before treatment.
• Bromocriptine is not used in uncontrolled hypertension; If you have preeclampsia/eclampsia or postpartum hypertension, make use decisions with the Pregnancy Heart Team. Monitor blood pressure, especially in the first days and during dose increases; In case of new hypertension, severe or persistent headache, visual impairment, or chest pain, discontinue the medication and seek immediate evaluation.
• If LVEF is exactly 30%, individualize the dosing schedule with the expert team.
• Excessive diuresis reduces intravascular volume; Titrate furosemide dose.
• Do not administer vasodilators in hypotension or cardiogenic shock.
• Avoid vasodilation and excessive diuresis leading to hypovolemia in hypertrophic cardiomyopathy; these can suddenly worsen outflow tract obstruction.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• Combined oral contraceptive is strictly contraindicated.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Do not give an ACE inhibitor in HCM with left ventricular outflow tract obstruction.
• Nitroglycerin: Start if systolic BP is above 110 mmHg.
• Enalapril: Contraindicated in pregnancy; Can be used during breastfeeding. If serum sodium is <130 mEq/L or serum creatinine is >1.6 mg/dL, start with 2.5 mg once daily under close supervision; The dose is increased every 4 days at the earliest unless there is severe hypotension or significant deterioration of renal function.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.

Approach

1. Manage with the Pregnancy Heart Team in the intensive care unit, consisting of cardiology, perinatology, anesthesia, intensive care, cardiac surgery and neonatal specialists.
2. Plan early referral to a center that can provide mechanical circulatory support (VA-ECMO or Impella).
3. Evaluate ventricular function and heart failure by ECHO; LVEF < 45% supports the diagnosis of peripartum cardiomyopathy.
4. Measure BNP/NT‑proBNP and troponin; Elevated troponin is associated with poor prognosis.
5. If the fetus has reached the limit of viability in cardiogenic shock, recommend combined spinal/epidural analgesia or emergency cesarean section under general anesthesia, taking into account the gestational age, accompanying diseases and the facilities of the center; Don't expect refractoriness. Prioritize maternal stabilization before the limit of viability and make the birth decision with the Pregnancy Heart Team.
6. Monitor fetal well-being with umbilical artery and middle cerebral artery (MCA) Doppler.
7. If the fetus has reached viability, perform intermittent or continuous fetal heart rate monitoring during hospitalization for maternal decompensation according to gestational age and clinical status; monitor continuously during anesthesia administration, labor, and delivery. Do not delay maternal stabilization for fetal assessment.
8. Closely monitor the first 24–72 hours after birth as the most critical period.
9. Individually evaluate the need for anticoagulation if there is significant low LVEF, atrial arrhythmia, or ventricular thrombus in other cardiomyopathies.
10. Plan discontinuation of heparin before planned delivery based on dose and risk of thrombosis; for neuraxial intervention, at least 12 hours must elapse after the last prophylactic dose of LMWH and at least 24 hours after the intermediate or therapeutic dose; plan postpartum resumption time if indication persists and there is no significant bleeding or significant risk of bleeding (general obstetric range 4–6 hours after vaginal birth, 6–12 hours after cesarean section).

Treatment

• Dobutamine: Start with 2–5 µg/kg/min IV infusion, titrating to 2–20 µg/kg/min according to response.
• Milrinone: 0.375–0.75 µg/kg/min IV infusion; If creatinine clearance is 10–50 mL/min, start with 0.0625–0.125 µg/kg/min and titrate carefully and do not exceed 0.375 µg/kg/min in significant renal impairment; If creatinine clearance is <10 mL/min, another agent is chosen; Hypotension may be prolonged in renal impairment.
• Levosimendan: 0.1 µg/kg/min IV infusion without loading dose; 0.05–0.2 µg/kg/min depending on response; The recommended infusion time is 24 hours.
• If hypotension persists despite inotrope — Noradrenaline: Start with 0.05 µg/kg/min IV infusion, titrate according to mean arterial pressure and organ perfusion; usual range 0.05–0.4 µg/kg/min, up to 1.0 µg/kg/min if necessary.
• In Hypoxemia — Oxygen: Oxygen is administered if SpO2 is below 90% or PaO2 is below 60 mmHg; SpO2 is maintained at least 90%, preferably 95% or above; If SpO2 remains below 95% despite oxygen or respiratory distress (respiratory rate >25/min) persists, noninvasive positive pressure ventilation is applied; Intubation and invasive ventilation are applied in progressive respiratory failure despite oxygen or noninvasive support.
• If accompanied by congestion — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in those who have not used diuretics before; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• Venoarterial ECMO (VA-ECMO) or percutaneous left ventricular assist device (Impella): apply as a bridge to transplant or myocardial recovery in inotrope-resistant shock.
• In PPCM with LVEF < 35% or intracardiac thrombus, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• If therapeutic anticoagulation is not applied and thromboprophylaxis is indicated (inpatient) — Enoxaparin (prophylactic): 40 mg SC once a day for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance is < 30 mL/min or if rapid reversal may be required for labor, neuraxial anesthesia, or emergency surgery, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH — UFH (SC, prophylactic): 5000–7500 IU in the 1st trimester, 7500–10 000 IU in the 2nd trimester, 10 000 IU SC every 12 hours in the 3rd trimester (dose is reduced if aPTT is prolonged).
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).

Note

• Positive inotropes such as digoxin, dobutamine and milrinone are contraindicated if there is left ventricular outflow tract obstruction in hypertrophic cardiomyopathy; Choose a vasoconstrictor that does not have an inotropic effect in hypotension with an expert team; Avoid vasodilation and excessive diuresis leading to hypovolemia.
• Individualize shock treatment in HCM without obstruction with impaired systolic function by an expert team according to ECHO and hemodynamics.
• Do not administer vasodilators in hypotension or cardiogenic shock.
• ACE inhibitor, ARB and ARNI are contraindicated during pregnancy.
• Avoid spironolactone during pregnancy; Review current therapy due to possible antiandrogenic effects and limited pregnancy safety data.
• If UFH is used, before neuraxial intervention: stop IV infusion at least 4–6 hours before; Wait 4–6 hours after SC 5000 IU (2–3 times a day), wait 12 hours after SC 7500–10 000 IU every 12 hours, wait 24 hours after single dose > 10 000 IU or total daily > 20 000 IU; In all cases, verify that coagulation (aPTT) is normal before intervention. Check platelet count if UFH has been used for more than 4 days.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Milrinone: Since it crosses the placenta during pregnancy, it is used only when the benefit outweighs the risk.
• Levosimendan: Not used in creatinine clearance <30 mL/min, severe liver failure, significant mechanical obstruction affecting ventricular filling or outflow, history of torsade de pointes, severe hypotension, and tachycardia; In hypotension, if necessary, it is given together with noradrenaline; The hemodynamic effect may last up to 9 days after the 24-hour infusion ends.
• Furosemide (IV): Since excessive diuresis during pregnancy may reduce uterine blood flow and placental perfusion, it is used with caution and the dose is titrated only in cases of pulmonary congestion or volume overload.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Manage with the Pregnancy Heart Team in the intensive care unit, consisting of cardiology, perinatology, anesthesia, intensive care, cardiac surgery and neonatal specialists.
2. Plan early referral to a center that can provide mechanical circulatory support (VA-ECMO or Impella).
3. Evaluate ventricular function and heart failure by ECHO; LVEF < 45% supports the diagnosis of peripartum cardiomyopathy.
4. Measure BNP/NT‑proBNP and troponin; Elevated troponin is associated with poor prognosis.
5. Closely monitor the first 24–72 hours after birth as the most critical period.
6. Individually evaluate the need for anticoagulation if there is significant low LVEF, atrial arrhythmia, or ventricular thrombus in other cardiomyopathies.
7. If anticoagulation remains indicated and there is no significant bleeding or significant risk of bleeding, plan for postpartum resumption; The general obstetric range is 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
8. Write the indication for anticoagulation and the end/reassessment date in the discharge plan: If anticoagulation is administered due to LVEF < 35%, continue for at least 6 weeks postpartum and reassess based on LVEF; If bromocriptine is used, maintain at least a prophylactic dose of LMWH throughout treatment; In case of intracardiac thrombus, embolism or permanent indication, the expert team determines the duration.

Treatment

• Dobutamine: Start with 2–5 µg/kg/min IV infusion, titrating to 2–20 µg/kg/min according to response.
• Milrinone: 0.375–0.75 µg/kg/min IV infusion; If creatinine clearance is 10–50 mL/min, start with 0.0625–0.125 µg/kg/min and titrate carefully and do not exceed 0.375 µg/kg/min in significant renal impairment; If creatinine clearance is <10 mL/min, another agent is chosen; Hypotension may be prolonged in renal impairment.
• Levosimendan: 0.1 µg/kg/min IV infusion without loading dose; 0.05–0.2 µg/kg/min depending on response; The recommended infusion time is 24 hours.
• If hypotension persists despite inotrope — Noradrenaline: Start with 0.05 µg/kg/min IV infusion, titrate according to mean arterial pressure and organ perfusion; usual range 0.05–0.4 µg/kg/min, up to 1.0 µg/kg/min if necessary.
• In Hypoxemia — Oxygen: Oxygen is administered if SpO2 is below 90% or PaO2 is below 60 mmHg; SpO2 is maintained at least 90%, preferably 95% or above; If SpO2 remains below 95% despite oxygen or respiratory distress (respiratory rate >25/min) persists, noninvasive positive pressure ventilation is applied; Intubation and invasive ventilation are applied in progressive respiratory failure despite oxygen or noninvasive support.
• If accompanied by congestion — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in those who have not used diuretics before; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• Venoarterial ECMO (VA-ECMO) or percutaneous left ventricular assist device (Impella): apply as a bridge to transplant or myocardial recovery in inotrope-resistant shock.
• Bromocriptine may be considered in moderate–severe PPCM: 2.5 mg twice daily for 2 weeks, followed by 2.5 mg once daily for 6 weeks; Add at least prophylactic dose of LMWH.
• In PPCM with LVEF < 35% or intracardiac thrombus, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• If therapeutic anticoagulation is not applied and thromboprophylaxis is indicated (inpatient, bromocriptine use) — Enoxaparin (prophylactic): 40 mg SC once a day for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance < 30 mL/min, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH — UFH (SC, prophylactic): 5000 IU SC every 8–12 hours after birth.
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• If bromocriptine is started in peripartum cardiomyopathy, breastfeeding cannot be continued during treatment; Discuss the baby's feeding plan before treatment.
• Bromocriptine is not used in uncontrolled hypertension; If you have preeclampsia/eclampsia or postpartum hypertension, make use decisions with the Pregnancy Heart Team. Monitor blood pressure, especially in the first days and during dose increases; In case of new hypertension, severe or persistent headache, visual impairment, or chest pain, discontinue the medication and seek immediate evaluation.
• If bromocriptine is considered if LVEF ≥ 30% with severe shock, individualize the dosing schedule with the specialist team.
• Positive inotropes such as digoxin, dobutamine and milrinone are contraindicated if there is left ventricular outflow tract obstruction in hypertrophic cardiomyopathy; Choose a vasoconstrictor that does not have an inotropic effect in hypotension with an expert team; Avoid vasodilation and excessive diuresis leading to hypovolemia.
• Individualize shock treatment in HCM without obstruction with impaired systolic function by an expert team according to ECHO and hemodynamics.
• Excessive diuresis reduces intravascular volume; Titrate furosemide dose.
• Do not administer vasodilators in hypotension or cardiogenic shock.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Combined oral contraceptive is strictly contraindicated.
• Levosimendan: Not used in creatinine clearance <30 mL/min, severe liver failure, significant mechanical obstruction affecting ventricular filling or outflow, history of torsade de pointes, severe hypotension, and tachycardia; In hypotension, if necessary, it is given together with noradrenaline; The hemodynamic effect may last up to 9 days after the 24-hour infusion ends.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.

Approach

1. Manage with the Pregnancy Heart Team in the intensive care unit, consisting of cardiology, perinatology, anesthesia, intensive care, cardiac surgery and neonatal specialists.
2. If the fetus has reached the limit of viability in cardiogenic shock, recommend combined spinal/epidural analgesia or emergency cesarean section under general anesthesia, taking into account the gestational age, accompanying diseases and the facilities of the center; Don't expect refractoriness. Prioritize maternal stabilization before the limit of viability and make the birth decision with the Pregnancy Heart Team.
3. Caesarean section can be performed under VA-ECMO or Impella support.
4. Monitor with ECHO, BNP/NT‑proBNP and troponin; Elevated troponin is associated with poor prognosis.
5. Monitor fetal well-being with umbilical artery and middle cerebral artery (MCA) Doppler.
6. If the fetus has reached viability, perform intermittent or continuous fetal heart rate monitoring during hospitalization for maternal decompensation according to gestational age and clinical status; monitor continuously during anesthesia administration, labor, and delivery. Do not delay maternal stabilization for fetal assessment.
7. Closely monitor the first 24–72 hours after birth as the most critical period.
8. Individually evaluate the need for anticoagulation if there is significant low LVEF, atrial arrhythmia, or ventricular thrombus in other cardiomyopathies.
9. Plan discontinuation of heparin before planned delivery based on dose and risk of thrombosis; for neuraxial intervention, at least 12 hours must elapse after the last prophylactic dose of LMWH and at least 24 hours after the intermediate or therapeutic dose; plan postpartum resumption time if indication persists and there is no significant bleeding or significant risk of bleeding (general obstetric range 4–6 hours after vaginal birth, 6–12 hours after cesarean section).

Treatment

• Bridge to transplant or myocardial recovery with venoarterial ECMO (VA-ECMO) or percutaneous left ventricular assist device (Impella).
• Dobutamine: Start with 2–5 µg/kg/min IV infusion, titrating to 2–20 µg/kg/min according to response.
• Milrinone: 0.375–0.75 µg/kg/min IV infusion; If creatinine clearance is 10–50 mL/min, start with 0.0625–0.125 µg/kg/min and titrate carefully and do not exceed 0.375 µg/kg/min in significant renal impairment; If creatinine clearance is <10 mL/min, another agent is chosen; Hypotension may be prolonged in renal impairment.
• Levosimendan: 0.1 µg/kg/min IV infusion without loading dose; 0.05–0.2 µg/kg/min depending on response; The recommended infusion time is 24 hours.
• If hypotension persists despite inotrope — Noradrenaline: Start with 0.05 µg/kg/min IV infusion, titrate according to mean arterial pressure and organ perfusion; usual range 0.05–0.4 µg/kg/min, up to 1.0 µg/kg/min if necessary.
• In Hypoxemia — Oxygen: Oxygen is administered if SpO2 is below 90% or PaO2 is below 60 mmHg; SpO2 is maintained at least 90%, preferably 95% or above; If SpO2 remains below 95% despite oxygen or respiratory distress (respiratory rate >25/min) persists, noninvasive positive pressure ventilation is applied; Intubation and invasive ventilation are applied in progressive respiratory failure despite oxygen or noninvasive support.
• If accompanied by congestion — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in those who have not used diuretics before; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• In PPCM with LVEF < 35% or intracardiac thrombus, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• If therapeutic anticoagulation is not applied and thromboprophylaxis is indicated (inpatient) — Enoxaparin (prophylactic): 40 mg SC once a day for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance is < 30 mL/min or if rapid reversal may be required for labor, neuraxial anesthesia, or emergency surgery, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH — UFH (SC, prophylactic): 5000–7500 IU in the 1st trimester, 7500–10 000 IU in the 2nd trimester, 10 000 IU SC every 12 hours in the 3rd trimester (dose is reduced if aPTT is prolonged).
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).

Note

• Positive inotropes such as digoxin, dobutamine and milrinone are contraindicated if there is left ventricular outflow tract obstruction in hypertrophic cardiomyopathy; Choose a vasoconstrictor that does not have an inotropic effect in hypotension with an expert team; Avoid vasodilation and excessive diuresis leading to hypovolemia.
• Individualize shock treatment in HCM without obstruction with impaired systolic function by an expert team according to ECHO and hemodynamics.
• Do not administer vasodilators in hypotension or cardiogenic shock.
• ACE inhibitor, ARB and ARNI are contraindicated during pregnancy.
• Avoid spironolactone during pregnancy; Review current therapy due to possible antiandrogenic effects and limited pregnancy safety data.
• If UFH is used, before neuraxial intervention: stop IV infusion at least 4–6 hours before; Wait 4–6 hours after SC 5000 IU (2–3 times a day), wait 12 hours after SC 7500–10 000 IU every 12 hours, wait 24 hours after single dose > 10 000 IU or total daily > 20 000 IU; In all cases, verify that coagulation (aPTT) is normal before intervention. Check platelet count if UFH has been used for more than 4 days.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Milrinone: Since it crosses the placenta during pregnancy, it is used only when the benefit outweighs the risk.
• Levosimendan: Not used in creatinine clearance <30 mL/min, severe liver failure, significant mechanical obstruction affecting ventricular filling or outflow, history of torsade de pointes, severe hypotension, and tachycardia; In hypotension, if necessary, it is given together with noradrenaline; The hemodynamic effect may last up to 9 days after the 24-hour infusion ends.
• Furosemide (IV): Since excessive diuresis during pregnancy may reduce uterine blood flow and placental perfusion, it is used with caution and the dose is titrated only in cases of pulmonary congestion or volume overload.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Manage with the Pregnancy Heart Team in the intensive care unit, consisting of cardiology, perinatology, anesthesia, intensive care, cardiac surgery and neonatal specialists.
2. Monitor with ECHO, BNP/NT‑proBNP and troponin; Elevated troponin is associated with poor prognosis.
3. Closely monitor the first 24–72 hours after birth as the most critical period.
4. Individually evaluate the need for anticoagulation if there is significant low LVEF, atrial arrhythmia, or ventricular thrombus in other cardiomyopathies.
5. If anticoagulation remains indicated and there is no significant bleeding or significant risk of bleeding, plan for postpartum resumption; The general obstetric range is 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
6. Write the indication for anticoagulation and the end/reassessment date in the discharge plan: If anticoagulation is administered due to LVEF < 35%, continue for at least 6 weeks postpartum and reassess based on LVEF; If bromocriptine is used, maintain at least a prophylactic dose of LMWH throughout treatment; In case of intracardiac thrombus, embolism or permanent indication, the expert team determines the duration.

Treatment

• Bridge to transplant or myocardial recovery with venoarterial ECMO (VA-ECMO) or percutaneous left ventricular assist device (Impella).
• Dobutamine: Start with 2–5 µg/kg/min IV infusion, titrating to 2–20 µg/kg/min according to response.
• Milrinone: 0.375–0.75 µg/kg/min IV infusion; If creatinine clearance is 10–50 mL/min, start with 0.0625–0.125 µg/kg/min and titrate carefully and do not exceed 0.375 µg/kg/min in significant renal impairment; If creatinine clearance is <10 mL/min, another agent is chosen; Hypotension may be prolonged in renal impairment.
• Levosimendan: 0.1 µg/kg/min IV infusion without loading dose; 0.05–0.2 µg/kg/min depending on response; The recommended infusion time is 24 hours.
• If hypotension persists despite inotrope — Noradrenaline: Start with 0.05 µg/kg/min IV infusion, titrate according to mean arterial pressure and organ perfusion; usual range 0.05–0.4 µg/kg/min, up to 1.0 µg/kg/min if necessary.
• In Hypoxemia — Oxygen: Oxygen is administered if SpO2 is below 90% or PaO2 is below 60 mmHg; SpO2 is maintained at least 90%, preferably 95% or above; If SpO2 remains below 95% despite oxygen or respiratory distress (respiratory rate >25/min) persists, noninvasive positive pressure ventilation is applied; Intubation and invasive ventilation are applied in progressive respiratory failure despite oxygen or noninvasive support.
• If accompanied by congestion — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in those who have not used diuretics before; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• Bromocriptine may be considered in moderate–severe PPCM: 2.5 mg twice daily for 2 weeks, followed by 2.5 mg once daily for 6 weeks; Add at least prophylactic dose of LMWH.
• In PPCM with LVEF < 35% or intracardiac thrombus, administer therapeutic dose of LMWH: enoxaparin 1 mg/kg SC every 12 hours.
• If therapeutic anticoagulation is not applied and thromboprophylaxis is indicated (inpatient, bromocriptine use) — Enoxaparin (prophylactic): 40 mg SC once a day for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance < 30 mL/min, instead of therapeutic LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after the loading dose, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• If creatinine clearance is < 30 mL/min, instead of prophylactic LMWH — UFH (SC, prophylactic): 5000 IU SC every 8–12 hours after birth.
• In active HIT, stop all heparin and start a non-heparin anticoagulant at therapeutic intensity even if thrombosis has not been demonstrated; by decision of the specialist team — Fondaparinux: for prophylaxis, 2.5 mg SC once daily; for active HIT or thrombosis requiring treatment, 5 mg SC once daily for body weight <50 kg, 7.5 mg SC once daily for 50–100 kg, and 10 mg SC once daily for >100 kg.
• In the past history of HIT, instead of LMWH and UFH, at the intensity required by the current indication — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• Contraception: insertion of a progestin implant or levonorgestrel-releasing intrauterine device before discharge.

Note

• If bromocriptine is started in peripartum cardiomyopathy, breastfeeding cannot be continued during treatment; Discuss the baby's feeding plan before treatment.
• Bromocriptine is not used in uncontrolled hypertension; If you have preeclampsia/eclampsia or postpartum hypertension, make use decisions with the Pregnancy Heart Team. Monitor blood pressure, especially in the first days and during dose increases; In case of new hypertension, severe or persistent headache, visual impairment, or chest pain, discontinue the medication and seek immediate evaluation.
• If bromocriptine is considered if LVEF ≥ 30% with severe shock, individualize the dosing schedule with the specialist team.
• Positive inotropes such as digoxin, dobutamine and milrinone are contraindicated if there is left ventricular outflow tract obstruction in hypertrophic cardiomyopathy; Choose a vasoconstrictor that does not have an inotropic effect in hypotension with an expert team; Avoid vasodilation and excessive diuresis leading to hypovolemia.
• Individualize shock treatment in HCM without obstruction with impaired systolic function by an expert team according to ECHO and hemodynamics.
• Excessive diuresis reduces intravascular volume; Titrate furosemide dose.
• Do not administer vasodilators in hypotension or cardiogenic shock.
• If neuraxial block was performed, initiate prophylactic LMWH at least 12 hours after the procedure, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• In case of shock, high bleeding risk or imminent need for emergency intervention, choose a short-acting IV non-heparin agent with an expert team.
• Combined oral contraceptive is strictly contraindicated.
• Levosimendan: Not used in creatinine clearance <30 mL/min, severe liver failure, significant mechanical obstruction affecting ventricular filling or outflow, history of torsade de pointes, severe hypotension, and tachycardia; In hypotension, if necessary, it is given together with noradrenaline; The hemodynamic effect may last up to 9 days after the 24-hour infusion ends.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.

Approach

1. Delay pregnancy until at least 1–2 years after transplantation, until the risk of acute rejection has decreased and graft function has stabilized.
2. Plan your pregnancy with the Pregnancy Heart Team.

Treatment

• Effective contraception: use a long-acting reversible method (intrauterine device, progestin implant) in most women during the deferral period.
• Azathioprine: start instead of mycophenolate mofetil when pregnancy is planned; Individualize the dose with the expert team.
• Maintain tacrolimus or cyclosporine with close monitoring of blood levels.

Note

• Mycophenolate mofetil is significantly teratogenic; When pregnancy is planned, stop at least 6-8 weeks before conception.

Approach

1. Pregnancy can be planned; risk class mWHO III.
2. Manage with the multidisciplinary Pregnancy Heart Team at the specialist center from pre-pregnancy.
3. State in counseling that complications are common and intensive antenatal, intrapartum and postpartum monitoring is required.
4. Explain that the risks of preeclampsia, preterm birth, and low birth weight remain high.
5. Document NYHA class, ECG, ECHO and baseline BNP/NT‑proBNP before pregnancy.

Treatment

• Azathioprine: start instead of mycophenolate mofetil when pregnancy is planned; Individualize the dose with the expert team.
• Maintain tacrolimus or cyclosporine with close monitoring of blood levels.

Note

• Mycophenolate mofetil is significantly teratogenic; Stop at least 6-8 weeks before getting pregnant.

Approach

1. Document rhythm with 12-lead ECG; perform rhythm monitoring if necessary; evaluate electrolytes, thyroid function, complete blood count, and ECHO; Look for triggers and structural heart disease.
2. Select treatment according to arrhythmia type (SVT, AF/atrial flutter, VT).
3. Control rhythm load early; Conduct maternal rhythm management together with fetal monitoring.
4. Put the birth and puerperium follow-up plan in writing.
5. Determine the mode of delivery according to obstetric indications; Isolated arrhythmia alone is not an indication for cesarean section.
6. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.

Treatment

• First step in SVT with narrow QRS—Vagal maneuver: modified Valsalva—15 seconds of straining (approximately 40 mmHg) against the closed glottis in a semi-sitting position, followed immediately by lying supine and lifting the legs 45° and holding for 15 seconds; Carotid sinus massage—first auscultating the carotid murmur, pressing the unilateral carotid sinus for 5–10 seconds.
• For acute SVT termination (first drug) — Adenosine: 6 mg rapid IV bolus (in 1–2 seconds), immediately followed by flushing with 20 mL saline; If tachycardia does not stop within 1–2 minutes, 12 mg rapid IV bolus; 12 mg once more if necessary.
• In acute rate control — Metoprolol: 2.5–5 mg IV over 2 minutes; If necessary, repeat every 5 minutes, maximum 15 mg in total.
• For rate control and maintenance of symptom suppression — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Alternative for rate control — Verapamil: 2.5–10 mg IV, slow bolus over 5 minutes; It can be repeated after 30 minutes if necessary.
• Alternative for rate control — Digoxin: 0.5 mg IV by slow injection over at least 5 minutes; additional dose of 0.25 mg every 6 hours if necessary; Total 8–12 µg/kg (calculated by lean body weight) and not exceeding 0.75–1.5 mg in 24 hours; If creatinine clearance is 15 mL/min or less, the dose is halved.
• In the absence of structural heart disease, in rhythm control — Flecainide: start at 50 mg orally every 12 hours (in ventricular arrhythmia, 50–100 mg every 12 hours); If necessary, increase each dose by 50 mg every 4 days at the earliest; Maximum daily dose is 300 mg in AF/flutter and SVT, 400 mg in ventricular arrhythmia; Every 12 hours, in divided doses every 8 hours if necessary.
• Rhythm control — Sotalol: start at 80 mg by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.

Note

• Do not use verapamil in LVEF < 40% or heart failure. Do not use diltiazem during pregnancy and breastfeeding.
• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Use flecainide and sotalol only under the supervision of a specialist team, in selected patients and with close ECG monitoring. Do not use flecainide in structural heart disease, previous myocardial infarction or LVEF ≤ 40% (addition to beta-blocker, based on expert judgment in ARVC). Sotalol may be used with expert judgment in selected structural heart disease and ARVC; It is not a routine option in severe left ventricular dysfunction (LVEF < 40%) and is not used in decompensated heart failure.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Do not use atenolol routinely; Choose a beta blocker with a safer profile.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Vagal maneuver: No pressure is applied to the eyeball.
• Adenosine: Given under continuous ECG recording; The initial dose is reduced to 3 mg in those receiving dipyridamole or carbamazepine, in those with heart transplantation and when given through the central vein; It is not given in bronchospasm or asthma, second-third degree AV block and sick sinus syndrome or symptomatic bradycardia (if there is no functional pacemaker); If advanced block develops with one dose, no additional dose is given.
• Metoprolol: Not given IV in decompensated heart failure (electrical cardioversion is preferred).
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Verapamil: Used only in patients with preserved LVEF; may cause maternal hypotension; If possible, adenosine or beta blocker is preferred in SVT, and IV beta-1 selective blocker is priority in AF/flutter rate control; It is not given concurrently with IV beta blockers; It is not given in pre-excitation (WPW) AF/flutter, ventricular tachycardia and wide QRS tachycardia of unknown supraventricular origin.
• Digoxin: Not given in the presence of pre-excitation (WPW); Dosage adjustment may be required after birth.
• Digoxin: Maternal serum digoxin level is closely monitored during pregnancy; In later stages of pregnancy, higher doses may be required for therapeutic levels.
• Flecainide: Not given in structural or ischemic heart disease. If there is no pre-excitation (WPW), it is used together with an AV node blocker such as a beta blocker against the risk of 1:1 AV conduction in atrial flutter; In WPW, no AV node blocker is added. After delivery, the increased dose during pregnancy is re-evaluated.
• Flecainide: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.

Approach

1. Document rhythm with 12-lead ECG; perform rhythm monitoring if necessary; Assess electrolytes, thyroid function, complete blood count, and ECHO.
2. Classify the documented rhythm as SVT, AF/flutter, or VT and select treatment based on arrhythmia type.
3. Consider other concomitant risk phenotypes together; If accompanied by hypertensive disease, keep the observation threshold low in the hospital; Consider advanced rhythm examination and genetic counseling in cases of suspected hereditary arrhythmia.
4. Risk stratify with mWHO, CARPREG II (previous arrhythmia 3 points) and ZAHARA in congenital heart disease.
5. Plan close follow-up at a tertiary center and evaluate by a multidisciplinary committee; Perform regular ECG/Holter monitoring.
6. Prepare a written antenatal emergency plan; establish the intrapartum emergency algorithm and team role assignments in writing.
7. Monitor fetal growth for risk of preterm birth and fetal growth restriction; If the mother or father has congenital heart disease, discuss the risk of recurrence in the fetus and recommend fetal echocardiography at 18–22 weeks
8. Apply pharmacological treatment aggressively in congenital heart disease as arrhythmia may trigger decompensation.
9. Determine the mode of delivery according to obstetric indications; do not routinely perform cesarean delivery.
10. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.

Treatment

• First step in SVT with narrow QRS—Vagal maneuver: modified Valsalva—15 seconds of straining (approximately 40 mmHg) against the closed glottis in a semi-sitting position, followed immediately by lying supine and lifting the legs 45° and holding for 15 seconds; Carotid sinus massage—first auscultating the carotid murmur, pressing the unilateral carotid sinus for 5–10 seconds.
• For acute SVT termination (first drug) — Adenosine: 6 mg rapid IV bolus (in 1–2 seconds), immediately followed by flushing with 20 mL saline; If tachycardia does not stop within 1–2 minutes, 12 mg rapid IV bolus; 12 mg once more if necessary.
• In acute rate control — Metoprolol: 2.5–5 mg IV over 2 minutes; If necessary, repeat every 5 minutes, maximum 15 mg in total.
• For rate control and maintenance of symptom suppression — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Alternative for rate control — Verapamil: 2.5–10 mg IV, slow bolus over 5 minutes; It can be repeated after 30 minutes if necessary.
• Alternative for rate control — Digoxin: 0.5 mg IV by slow injection over at least 5 minutes; additional dose of 0.25 mg every 6 hours if necessary; Total 8–12 µg/kg (calculated by lean body weight) and not exceeding 0.75–1.5 mg in 24 hours; If creatinine clearance is 15 mL/min or less, the dose is halved.
• Rhythm control in a selected patient with preserved LVEF and no heart failure — Sotalol: 80 mg is started by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.
• Consider catheter ablation in refractory arrhythmia with individual risk–benefit assessment in an experienced center.

Note

• Do not use verapamil in LVEF < 40% or heart failure. Do not use diltiazem during pregnancy and breastfeeding.
• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Use flecainide and sotalol only under the supervision of a specialist team, in selected patients and with close ECG monitoring. Do not use flecainide in structural heart disease, previous myocardial infarction or LVEF ≤ 40% (addition to beta-blocker, based on expert judgment in ARVC). Sotalol may be used with expert judgment in selected structural heart disease and ARVC; It is not a routine option in severe left ventricular dysfunction (LVEF < 40%) and is not used in decompensated heart failure.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Vagal maneuver: No pressure is applied to the eyeball.
• Adenosine: Given under continuous ECG recording; The initial dose is reduced to 3 mg in those receiving dipyridamole or carbamazepine, in those with heart transplantation and when given through the central vein; It is not given in bronchospasm or asthma, second-third degree AV block and sick sinus syndrome or symptomatic bradycardia (if there is no functional pacemaker); If advanced block develops with one dose, no additional dose is given.
• Metoprolol: Not given IV in decompensated heart failure (electrical cardioversion is preferred).
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Verapamil: Used only in patients with preserved LVEF; may cause maternal hypotension; If possible, adenosine or beta blocker is preferred in SVT, and IV beta-1 selective blocker is priority in AF/flutter rate control; It is not given concurrently with IV beta blockers; It is not given in pre-excitation (WPW) AF/flutter, ventricular tachycardia and wide QRS tachycardia of unknown supraventricular origin.
• Digoxin: Not given in the presence of pre-excitation (WPW); Dosage adjustment may be required after birth.
• Digoxin: Maternal serum digoxin level is closely monitored during pregnancy; In later stages of pregnancy, higher doses may be required for therapeutic levels.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.

Approach

1. Document rhythm with 12-lead ECG; perform rhythm monitoring if necessary; Assess electrolytes, thyroid function, complete blood count, and ECHO.
2. Classify the documented rhythm as SVT, AF/flutter, or VT and select treatment based on arrhythmia type.
3. Consider other concomitant risk phenotypes together; If accompanied by hypertensive disease, keep the observation threshold low in the hospital; Consider advanced rhythm examination and genetic counseling in cases of suspected hereditary arrhythmia.
4. Provide cardiology–obstetrics co-management; evaluate by a multidisciplinary committee at a tertiary center; Closely monitor for decreased effort capacity, recurrent tachyarrhythmia, and tendency to decompensation.
5. Save LVEF and NYHA functional class. If LVEF < 30% or NYHA III–IV heart failure, consider mWHO IV; Discuss the maternal risk, continuation in a specialist center and, if legally and ethically appropriate, the option of terminating the pregnancy in the early period.
6. LVEF < 35% or if thrombus is present, therapeutic anticoagulation required; In other conditions, such as atrial arrhythmia, individualize anticoagulation according to thromboembolic risk.
7. Monitor fetal growth with serial ultrasonography and fetal well-being with umbilical artery and middle cerebral artery Doppler.
8. Prepare a written birth plan at approximately week 32; Determine birth order emergency algorithm and team tasks.
9. Vaginal delivery is recommended for most cardiomyopathies; Caesarean section is preferred if there is obstetric indication, severe heart failure (LVEF < 30% and/or NYHA III–IV), uncontrolled arrhythmia, outflow tract obstruction ≥ 50 mmHg in HCM, or labor under VKA (warfarin).
10. Administer epidural analgesia, initiated early in labor and continued without interruption; Avoid excessive vasodilation in HCM; Use assisted vaginal birth in conjunction with cardiology based on individual risk assessment to shorten the second stage.
11. Intensify postpartum monitoring; plan proactive monitoring for recurrence in the first weeks and early check-up before discharge; teach warning signs and review antiarrhythmic therapy for breastfeeding compatibility.
12. Closely monitor patients with reduced myocardial reserve for pulmonary edema, hypoxia and cardiogenic shock, especially in the first 24–72 hours after birth.

Treatment

• First step in SVT with narrow QRS—Vagal maneuver: modified Valsalva—15 seconds of straining (approximately 40 mmHg) against the closed glottis in a semi-sitting position, followed immediately by lying supine and lifting the legs 45° and holding for 15 seconds; Carotid sinus massage—first auscultating the carotid murmur, pressing the unilateral carotid sinus for 5–10 seconds.
• For acute SVT termination (first drug) — Adenosine: 6 mg rapid IV bolus (in 1–2 seconds), immediately followed by flushing with 20 mL saline; If tachycardia does not stop within 1–2 minutes, 12 mg rapid IV bolus; 12 mg once more if necessary.
• In low LVEF/heart failure only in stable and euvolemic patients; In this case, the long-acting form of succinate or bisoprolol is preferred; if using non-selective beta blocker, switch to beta-1 selective — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• In ARVC, if there is no left ventricular systolic dysfunction, first-line antiarrhythmic in addition to beta-blocker — Flecainide: oral 50 mg every 12 hours is started (50–100 mg every 12 hours in ventricular arrhythmia); If necessary, increase each dose by 50 mg every 4 days at the earliest; Maximum daily dose is 300 mg in AF/flutter and SVT, 400 mg in ventricular arrhythmia; Every 12 hours, in divided doses every 8 hours if necessary.
• In ARVC or selected cardiomyopathy with preserved LVEF, rhythm control by expert judgment — Sotalol: start at 80 mg by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.
• If there is documented intracardiac thrombus or LVEF < 35% in cardiomyopathy (including PPCM), therapeutic dose LMWH (enoxaparin): 1 mg/kg SC based on early pregnancy weight every 12 hours (if renal function is appropriate).
• If bromocriptine is used in PPCM (minimum prophylactic dose) — Enoxaparin (prophylactic): 40 mg SC once daily under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• When using bromocriptine in PPCM, if LVEF < 35%, intracardiac thrombus or AF with high thromboembolic risk, therapeutic dose LMWH (enoxaparin): 1 mg/kg SC every 12 hours according to early pregnancy weight.
• At birth, by slow infusion rather than rapid IV bolus — Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).

Note

• Avoid positive inotropes (digoxin, dobutamine) and hypovolemia, excessive diuresis, vasodilation and tachycardia in HCM.
• In ARVC, do not discontinue beta-blocker therapy, including sotalol, during pregnancy or the postpartum period; reprogram the ICD appropriately.
• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Use flecainide and sotalol only under the supervision of a specialist team, in selected patients and with close ECG monitoring. Do not use flecainide in structural heart disease, previous myocardial infarction or LVEF ≤ 40% (addition to beta-blocker, based on expert judgment in ARVC). Sotalol may be used with expert judgment in selected structural heart disease and ARVC; It is not a routine option in severe left ventricular dysfunction (LVEF < 40%) and is not used in decompensated heart failure.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Assess renal function before enoxaparin; if creatinine clearance is <30 mL/min, do not apply the standard regimens unchanged; reduce the dose according to renal function or consider UFH with the specialist team.
• Vagal maneuver: No pressure is applied to the eyeball.
• Adenosine: Given under continuous ECG recording; The initial dose is reduced to 3 mg in those receiving dipyridamole or carbamazepine, in those with heart transplantation and when given through the central vein; It is not given in bronchospasm or asthma, second-third degree AV block and sick sinus syndrome or symptomatic bradycardia (if there is no functional pacemaker); If advanced block develops with one dose, no additional dose is given.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Bisoprolol: Started only in stable and euvolemic patients.
• Flecainide: Not given in structural or ischemic heart disease. If there is no pre-excitation (WPW), it is used together with an AV node blocker such as a beta blocker against the risk of 1:1 AV conduction in atrial flutter; In WPW, no AV node blocker is added. After delivery, the increased dose during pregnancy is re-evaluated.
• Flecainide: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Document the rhythm early with a 12-lead ECG; perform rhythm monitoring if necessary; Assess electrolytes, thyroid function, complete blood count, and ECHO.
2. Classify the documented rhythm as SVT, AF/flutter, or VT and select treatment based on arrhythmia type.
3. Consider other concomitant risk phenotypes together; If accompanied by hypertensive disease, keep the observation threshold low in the hospital; Consider advanced rhythm examination and genetic counseling in cases of suspected hereditary arrhythmia.
4. Perform joint maternal–fetal assessment; Consider cardiac findings as maternal risk indicators that can directly determine the timing of birth.
5. Refer to a tertiary center and evaluate by a multidisciplinary committee.
6. Determine the birth order emergency algorithm and team task distribution in writing.
7. Determine the mode of delivery according to obstetric indications; Isolated arrhythmia alone is not an indication for cesarean section.
8. Proactively monitor for arrhythmia recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review medications for breastfeeding compatibility.

Treatment

• First step in SVT with narrow QRS—Vagal maneuver: modified Valsalva—15 seconds of straining (approximately 40 mmHg) against the closed glottis in a semi-sitting position, followed immediately by lying supine and lifting the legs 45° and holding for 15 seconds; Carotid sinus massage—first auscultating the carotid murmur, pressing the unilateral carotid sinus for 5–10 seconds.
• For acute SVT termination (first drug) — Adenosine: 6 mg rapid IV bolus (in 1–2 seconds), immediately followed by flushing with 20 mL saline; If tachycardia does not stop within 1–2 minutes, 12 mg rapid IV bolus; 12 mg once more if necessary.
• In acute rate control — Metoprolol: 2.5–5 mg IV over 2 minutes; If necessary, repeat every 5 minutes, maximum 15 mg in total.
• For rate control and maintenance of symptom suppression — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Alternative for rate control — Verapamil: 2.5–10 mg IV, slow bolus over 5 minutes; It can be repeated after 30 minutes if necessary.
• Alternative for rate control — Digoxin: 0.5 mg IV by slow injection over at least 5 minutes; additional dose of 0.25 mg every 6 hours if necessary; Total 8–12 µg/kg (calculated by lean body weight) and not exceeding 0.75–1.5 mg in 24 hours; If creatinine clearance is 15 mL/min or less, the dose is halved.
• Treat acute severe hypertension without delay; Select the agent and dose from the 'Acute severe hypertension' algorithm.
• In the absence of structural heart disease, in rhythm control — Flecainide: start at 50 mg orally every 12 hours (in ventricular arrhythmia, 50–100 mg every 12 hours); If necessary, increase each dose by 50 mg every 4 days at the earliest; Maximum daily dose is 300 mg in AF/flutter and SVT, 400 mg in ventricular arrhythmia; Every 12 hours, in divided doses every 8 hours if necessary.
• Rhythm control — Sotalol: start at 80 mg by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.

Note

• Do not use verapamil in LVEF < 40% or heart failure. Do not use diltiazem during pregnancy and breastfeeding.
• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Do not use labetalol in bradycardia, heart block, decompensated heart function, or asthma.
• Use flecainide and sotalol only under the supervision of a specialist team, in selected patients and with close ECG monitoring. Do not use flecainide in structural heart disease, previous myocardial infarction or LVEF ≤ 40% (addition to beta-blocker, based on expert judgment in ARVC). Sotalol may be used with expert judgment in selected structural heart disease and ARVC; It is not a routine option in severe left ventricular dysfunction (LVEF < 40%) and is not used in decompensated heart failure.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Vagal maneuver: No pressure is applied to the eyeball.
• Adenosine: Given under continuous ECG recording; The initial dose is reduced to 3 mg in those receiving dipyridamole or carbamazepine, in those with heart transplantation and when given through the central vein; It is not given in bronchospasm or asthma, second-third degree AV block and sick sinus syndrome or symptomatic bradycardia (if there is no functional pacemaker); If advanced block develops with one dose, no additional dose is given.
• Metoprolol: Not given IV in decompensated heart failure (electrical cardioversion is preferred).
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Verapamil: Used only in patients with preserved LVEF; may cause maternal hypotension; If possible, adenosine or beta blocker is preferred in SVT, and IV beta-1 selective blocker is priority in AF/flutter rate control; It is not given concurrently with IV beta blockers; It is not given in pre-excitation (WPW) AF/flutter, ventricular tachycardia and wide QRS tachycardia of unknown supraventricular origin.
• Digoxin: Not given in the presence of pre-excitation (WPW); Dosage adjustment may be required after birth.
• Digoxin: Maternal serum digoxin level is closely monitored during pregnancy; In later stages of pregnancy, higher doses may be required for therapeutic levels.
• Flecainide: Not given in structural or ischemic heart disease. If there is no pre-excitation (WPW), it is used together with an AV node blocker such as a beta blocker against the risk of 1:1 AV conduction in atrial flutter; In WPW, no AV node blocker is added. After delivery, the increased dose during pregnancy is re-evaluated.
• Flecainide: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.

Approach

1. Document rhythm with 12-lead ECG; perform rhythm monitoring if necessary; Assess electrolytes, thyroid function, complete blood count, and ECHO.
2. Classify the documented rhythm as SVT, AF/flutter, or VT and select treatment based on arrhythmia type.
3. Consider other concomitant risk phenotypes together; If accompanied by hypertensive disease, keep the observation threshold low in the hospital; Consider advanced rhythm examination and genetic counseling in cases of suspected hereditary arrhythmia.
4. Refer to a tertiary center with a low threshold and evaluate by a multidisciplinary committee; Assess the need for electrophysiology consultation.
5. Assess ventricular function, ischemic disease, cardiomyopathy, hereditary channelopathies, and family history of sudden cardiac death.
6. ICD indications do not change during pregnancy; If there is an indication, perform the procedure with a plan adapted to mother-fetus safety.
7. Prepare an individualized birth-puerperium plan; Determine the intrapartum emergency algorithm and team tasks in writing.
8. Conduct maternal rhythm management in conjunction with fetal monitoring.
9. Determine the mode of delivery according to obstetric indications; Isolated arrhythmia alone is not an indication for cesarean section.
10. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.

Treatment

• If hemodynamically unstable — Synchronized electrical cardioversion: initial energy on biphasic device 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• In pulseless VT/VF — Defibrillation: manufacturer's recommended energy on a biphasic device (initial 120–200 J), highest device energy if unknown; subsequent shocks with the same or higher energy; 360 J in monophasic device; The pads are placed anterolaterally, and the lateral pad is placed under or next to the breast tissue.
• If there is no pulse (cardiac arrest in pregnancy): immediately initiate high-quality cardiopulmonary resuscitation (CPR) and cardiac arrest algorithm; if the fundus is at or above the umbilicus, perform continuous manual left lateral uterine displacement with chest compression; Start resuscitative birth preparation at the diagnosis of arrest; If spontaneous circulation does not return with standard resuscitation, aim to complete the birth at the arrest site within the first 5 minutes.
• In polymorphic VT due to prolonged QT / torsades de pointes with a pulse (discontinue instigating drugs, restore potassium) — Magnesium sulfate: 1–2 g IV over 15 minutes; If there is no response or torsades de pointes recurs, repeat up to a total of 4 g in 1 hour; followed by 0.5–1 g/h IV infusion if necessary.
• In pulseless torsades de pointes, with defibrillation: magnesium sulfate 2 g IV/IO over at least 1–2 minutes; if ineffective, 2 g bolus up to 2 more times (maximum 6 g total).
• Except for Brugada syndrome, in emergency control of ventricular arrhythmia (advanced center) — Lidocaine: 1–1.5 mg/kg IV bolus, at a rate of 25–50 mg/min; additional bolus of 0.5–0.75 mg/kg every 5–10 minutes if necessary; Cumulative dose in one hour is up to 3 mg/kg and 300 mg; maintenance 1–4 mg/min IV infusion.
• If beta blocker is required — Propranolol (oral): 60–320 mg daily in divided doses every 6–12 hours.
• As a beta blocker if diagnosed with long QT or CPVT — Nadolol: 40–80 mg once daily; up to 240 mg if necessary.
• If syncope, VT or cardiac arrest develops despite beta blocker in CPVT or is stable on beta blocker–flecainide combination before pregnancy, in addition to beta blocker (continue both drugs throughout pregnancy and puerperium) — Flecainide: oral 50 mg every 12 hours is started (50–100 mg every 12 hours in ventricular arrhythmia); If necessary, increase each dose by 50 mg every 4 days at the earliest; Maximum daily dose is 300 mg in AF/flutter and SVT, 400 mg in ventricular arrhythmia; Every 12 hours, in divided doses every 8 hours if necessary.

Note

• Avoid drugs that prolong QT (including class IA, such as procainamide) in long QT syndrome.
• Do not use atenolol routinely; Choose a beta blocker with a safer profile.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Avoid sodium channel blockers (procainamide, flecainide) in Brugada syndrome; Anesthetics/antiarrhythmics that block the sodium channel, such as propofol and lidocaine, can trigger arrhythmia, select anesthetic drugs according to the list of drugs to avoid in Brugada; Treat fever immediately. Quinidine is a treatment used with expert judgment in Brugada and short QT syndrome; is not covered by this avoidance warning.
• Do not administer adrenaline for ventricular arrhythmia or cardiac arrest due to CPVT; after defibrillation, manage with an IV beta blocker, flecainide, and anesthesia/sedation; do not delay defibrillation.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Defibrillation: During pregnancy, the energy is the same as in non-pregnancy; if the fundus is at or above the umbilicus, manual left lateral uterine displacement is performed with chest compressions; Once cardiac arrest is diagnosed, external and internal fetal monitors are removed; Resuscitation and shock are not delayed for fetal assessment, fetal monitoring, or removal of monitors.
• Magnesium sulfate: If the patellar reflex disappears or the serum level exceeds 6 mEq/L, the infusion is discontinued.
• Lidocaine: All lidocaine doses, including lidocaine given for regional anesthesia, are included in the total dose.
• Propranolol (oral): After delivery, increased dosage in pregnancy is reconsidered.
• Propranolol (oral): Lowest effective dose used in pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.
• Nadolol: After delivery, increased dosage in pregnancy is reconsidered.
• Nadolol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.
• Flecainide: Not given in structural or ischemic heart disease. If there is no pre-excitation (WPW), it is used together with an AV node blocker such as a beta blocker against the risk of 1:1 AV conduction in atrial flutter; In WPW, no AV node blocker is added. After delivery, the increased dose during pregnancy is re-evaluated.
• Flecainide: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.

Approach

1. Document rhythm with 12-lead ECG; perform rhythm monitoring if necessary; Assess electrolytes, thyroid function, complete blood count, and ECHO.
2. Classify the documented rhythm as SVT, AF/flutter, or VT and select treatment based on arrhythmia type.
3. Consider other concomitant risk phenotypes together; If accompanied by hypertensive disease, keep the observation threshold low in the hospital; Consider advanced rhythm examination and genetic counseling in cases of suspected hereditary arrhythmia.
4. Refer to a tertiary center with a low threshold and perform multidisciplinary evaluation without assuming a diagnosis of hereditary arrhythmia; Assess the need for electrophysiology consultation.
5. Perform advanced rhythm review; Assess ventricular function, ischemic disease, cardiomyopathy, hereditary channelopathies, and family history of sudden cardiac death.
6. ICD indications do not change during pregnancy; If there is an indication, perform the procedure with a plan adapted to mother-fetus safety.
7. Determine in writing the birth order emergency algorithm and team task distribution; Write down your birth and puerperium follow-up plan.
8. Conduct maternal rhythm management in conjunction with fetal monitoring.
9. Determine the mode of delivery according to obstetric indications; Isolated arrhythmia alone is not an indication for cesarean section.
10. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.

Treatment

• If hemodynamically unstable — Synchronized electrical cardioversion: initial energy on biphasic device 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• In pulseless VT/VF — Defibrillation: manufacturer's recommended energy on a biphasic device (initial 120–200 J), highest device energy if unknown; subsequent shocks with the same or higher energy; 360 J in monophasic device; The pads are placed anterolaterally, and the lateral pad is placed under or next to the breast tissue.
• If there is no pulse (cardiac arrest in pregnancy): immediately initiate high-quality cardiopulmonary resuscitation (CPR) and cardiac arrest algorithm; if the fundus is at or above the umbilicus, perform continuous manual left lateral uterine displacement with chest compression; Start resuscitative birth preparation at the diagnosis of arrest; If spontaneous circulation does not return with standard resuscitation, aim to complete the birth at the arrest site within the first 5 minutes.
• In polymorphic VT due to prolonged QT / torsades de pointes with a pulse (discontinue instigating drugs, restore potassium) — Magnesium sulfate: 1–2 g IV over 15 minutes; If there is no response or torsades de pointes recurs, repeat up to a total of 4 g in 1 hour; followed by 0.5–1 g/h IV infusion if necessary.
• In pulseless torsades de pointes, with defibrillation: magnesium sulfate 2 g IV/IO over at least 1–2 minutes; if ineffective, 2 g bolus up to 2 more times (maximum 6 g total).
• In emergency control of ventricular arrhythmia (advanced center) — Lidocaine: 1–1.5 mg/kg IV bolus, at a rate of 25–50 mg/min; additional bolus of 0.5–0.75 mg/kg every 5–10 minutes if necessary; Cumulative dose in one hour is up to 3 mg/kg and 300 mg; maintenance 1–4 mg/min IV infusion.
• In the absence of prolonged QT and torsade, emergency control of ventricular arrhythmia (in advanced center) — Procainamide: 15 mg/kg IV loading over at least 30 minutes and with an infusion rate not exceeding 50 mg/min (total loading not more than 17 mg/kg); followed by 1–4 mg/min IV infusion.
• Beta blocker required — Metoprolol (oral): immediate-release tartrate start at 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Consider catheter ablation in refractory arrhythmia with individual risk–benefit assessment in an experienced center.

Note

• Do not use atenolol routinely; Choose a beta blocker with a safer profile.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Defibrillation: During pregnancy, the energy is the same as in non-pregnancy; if the fundus is at or above the umbilicus, manual left lateral uterine displacement is performed with chest compressions; Once cardiac arrest is diagnosed, external and internal fetal monitors are removed; Resuscitation and shock are not delayed for fetal assessment, fetal monitoring, or removal of monitors.
• Magnesium sulfate: If the patellar reflex disappears or the serum level exceeds 6 mEq/L, the infusion is discontinued.
• Lidocaine: All lidocaine doses, including lidocaine given for regional anesthesia, are included in the total dose.
• Procainamide: Stop loading if arrhythmia is suppressed, hypotension develops, or QRS duration is prolonged by more than 50%; It is avoided in prolonged QT and heart failure.
• Procainamide: Uterine irritability and preterm labor have been reported with IV use during pregnancy.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.

Approach

1. Start treatment without waiting for detailed rhythm classification; Provide maternal stabilization first.
2. After stabilization, evaluate triggers and structural heart disease with 12-lead ECG, rhythm monitoring, electrolytes, thyroid functions, complete blood count and ECHO.
3. If there is syncope/presyncope, previous sustained VT/VF, ventricular dysfunction/cardiomyopathy, complex congenital heart disease, new arrhythmia in hypertensive disease of pregnancy, or family history of sudden cardiac death at an early age, refer to a tertiary center with a low threshold and evaluate by a multidisciplinary committee.
4. Conduct maternal rhythm management in conjunction with fetal monitoring.
5. Put the birth and puerperium follow-up plan in writing.
6. Determine the mode of delivery according to obstetric indications; Isolated arrhythmia alone is not an indication for cesarean section.
7. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.

Treatment

• Synchronized electrical cardioversion: initial energy on the biphasic device is 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.

Note

• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.

Approach

1. Document rhythm with 12-lead ECG; perform rhythm monitoring if necessary; evaluate electrolytes, thyroid function, complete blood count, and ECHO; Look for triggers and structural heart disease.
2. If there is syncope/presyncope, previous sustained VT/VF, ventricular dysfunction/cardiomyopathy, complex congenital heart disease, new arrhythmia in hypertensive disease of pregnancy, or family history of sudden cardiac death at an early age, refer to a tertiary center with a low threshold and evaluate by a multidisciplinary committee.
3. Conduct maternal rhythm management in conjunction with fetal monitoring.
4. Put the birth and puerperium follow-up plan in writing.
5. Determine the mode of delivery according to obstetric indications; Isolated arrhythmia alone is not an indication for cesarean section.
6. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.

Treatment

• First step — Vagal maneuver: modified Valsalva—15 seconds of straining (approximately 40 mmHg) against the closed glottis in a semi-sitting position, followed immediately by lying supine and lifting the legs 45° and holding for 15 seconds; Carotid sinus massage—first auscultating the carotid murmur, pressing the unilateral carotid sinus for 5–10 seconds.
• If vagal maneuver unresponsive (first drug) — Adenosine: 6 mg rapid IV bolus (over 1–2 seconds), immediately followed by flushing with 20 mL saline; If tachycardia does not stop within 1–2 minutes, 12 mg rapid IV bolus; 12 mg once more if necessary.
• In acute rate control — Metoprolol: 2.5–5 mg IV over 2 minutes; If necessary, repeat every 5 minutes, maximum 15 mg in total.
• Alternative in SVT termination or rate control — Verapamil: 2.5–10 mg IV, slow bolus over 5 minutes; It can be repeated after 30 minutes if necessary.
• In symptomatic SVT that is drug-resistant or drug-inappropriate — Synchronized electrical cardioversion: initial energy on a biphasic device is 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• For rate control and maintenance of symptom suppression — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Alternative for rate control maintenance — Digoxin: oral maintenance 0.125–0.5 mg daily divided into 2 doses; The dose is adjusted according to the serum digoxin level.

Note

• Do not use verapamil in LVEF < 40% or heart failure. Do not use diltiazem during pregnancy and breastfeeding.
• Do not use positive inotropes such as digoxin and dobutamine if HCM is present.
• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Vagal maneuver: No pressure is applied to the eyeball.
• Adenosine: Given under continuous ECG recording; The initial dose is reduced to 3 mg in those receiving dipyridamole or carbamazepine, in those with heart transplantation and when given through the central vein; It is not given in bronchospasm or asthma, second-third degree AV block and sick sinus syndrome or symptomatic bradycardia (if there is no functional pacemaker); If advanced block develops with one dose, no additional dose is given.
• Metoprolol: Not given IV in decompensated heart failure (electrical cardioversion is preferred).
• Verapamil: Used only in patients with preserved LVEF; may cause maternal hypotension; If possible, adenosine or beta blocker is preferred in SVT, and IV beta-1 selective blocker is priority in AF/flutter rate control; It is not given concurrently with IV beta blockers; It is not given in pre-excitation (WPW) AF/flutter, ventricular tachycardia and wide QRS tachycardia of unknown supraventricular origin.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Digoxin: Not given in the presence of pre-excitation (WPW); Dosage adjustment may be required after birth.
• Digoxin: Maternal serum digoxin level is closely monitored during pregnancy; In later stages of pregnancy, higher doses may be required for therapeutic levels.

Approach

1. Classify as mWHO II; Provide individualized counseling.
2. Perform cardiology check at least once per trimester.
3. Delivery may take place at the local hospital if specialist consultation and a pathway for transfer to a higher-level center are available.
4. Control rhythm load early; Conduct maternal rhythm management together with fetal monitoring.
5. Put the birth and puerperium follow-up plan in writing.
6. Determine the mode of delivery according to obstetric indications; Isolated arrhythmia alone is not an indication for cesarean section.
7. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.

Treatment

• First step in an SVT episode — Vagal maneuvers: modified Valsalva—straining against a closed glottis for 15 seconds (approximately 40 mmHg) in a semi-recumbent position, immediately followed by laying the patient supine and elevating the legs to 45° for 15 seconds; carotid sinus massage—first auscultate for a carotid bruit, then apply unilateral carotid sinus pressure for 5–10 seconds.
• For acute termination of an SVT attack (first drug) — Adenosine: 6 mg rapid IV bolus (in 1–2 seconds), immediately followed by flushing with 20 mL physiological saline; If tachycardia does not stop within 1–2 minutes, 12 mg rapid IV bolus; 12 mg once more if necessary.
• For prophylaxis, rate control and symptom suppression — Metoprolol (oral): immediate-release tartrate start at 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• If LVEF is normal and there is no heart failure, alternative prophylaxis — Verapamil (oral): immediate-release form is started at 40 mg 3–4 times a day, increased according to heart rate control; maintenance 120–480 mg per day, maximum 480 mg per day.
• Alternative for rate control maintenance — Digoxin: oral maintenance 0.125–0.5 mg daily divided into 2 doses; The dose is adjusted according to the serum digoxin level.
• As first choice if there is pre-excitation (WPW) on the resting ECG, in SVT resistant to beta-blockers or verapamil if there is no pre-excitation — Flecainide: oral 50 mg every 12 hours is started (50–100 mg every 12 hours in ventricular arrhythmia); If necessary, increase each dose by 50 mg every 4 days at the earliest; Maximum daily dose is 300 mg in AF/flutter and SVT, 400 mg in ventricular arrhythmia; Every 12 hours, in divided doses every 8 hours if necessary.
• Rhythm control — Sotalol: start at 80 mg by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.
• Consider catheter ablation in refractory arrhythmia with individual risk–benefit assessment in an experienced center.

Note

• Do not use atenolol routinely; Choose a beta blocker with a safer profile. Avoid inappropriate prophylactic medication strategies.
• Do not use verapamil in LVEF < 40% or heart failure. Do not use diltiazem during pregnancy and breastfeeding.
• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Use flecainide and sotalol only under the supervision of a specialist team, in selected patients and with close ECG monitoring. Do not use flecainide in structural heart disease, previous myocardial infarction or LVEF ≤ 40% (addition to beta-blocker, based on expert judgment in ARVC). Sotalol may be used with expert judgment in selected structural heart disease and ARVC; It is not a routine option in severe left ventricular dysfunction (LVEF < 40%) and is not used in decompensated heart failure.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Vagal maneuver: No pressure is applied to the eyeball.
• Adenosine: Given under continuous ECG recording; The initial dose is reduced to 3 mg in those receiving dipyridamole or carbamazepine, in those with heart transplantation and when given through the central vein; It is not given in bronchospasm or asthma, second-third degree AV block and sick sinus syndrome or symptomatic bradycardia (if there is no functional pacemaker); If advanced block develops with one dose, no additional dose is given.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Verapamil (oral): Not administered in the presence of pre-excitation (WPW) or in patients with reduced LVEF. Postpartum, any dose increased during pregnancy should be re-evaluated.
• Verapamil (oral): Lowest effective dose used in pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.
• Digoxin: Not given in the presence of pre-excitation (WPW); Dosage adjustment may be required after birth.
• Digoxin: Maternal serum digoxin level is closely monitored during pregnancy; In later stages of pregnancy, higher doses may be required for therapeutic levels.
• Flecainide: Not given in structural or ischemic heart disease. If there is no pre-excitation (WPW), it is used together with an AV node blocker such as a beta blocker against the risk of 1:1 AV conduction in atrial flutter; In WPW, no AV node blocker is added. After delivery, the increased dose during pregnancy is re-evaluated.
• Flecainide: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.

Approach

1. Plan close follow-up at a tertiary center and evaluate by a multidisciplinary committee; Perform regular ECG/Holter monitoring.
2. Risk stratify with mWHO, CARPREG II (previous arrhythmia 3 points) and ZAHARA in congenital heart disease.
3. Prepare a written antenatal emergency plan; establish the intrapartum emergency algorithm and team role assignments in writing.
4. Plan cardiology-gynecology joint management and intensified puerperal monitoring in cardiomyopathy.
5. Monitor fetal growth for risk of preterm birth and fetal growth restriction; If the mother or father has congenital heart disease, discuss the risk of recurrence in the fetus and recommend fetal echocardiography at 18–22 weeks
6. Apply pharmacological treatment aggressively in congenital heart disease as arrhythmia may trigger decompensation.
7. Determine the mode of delivery according to obstetric indications; do not routinely perform cesarean delivery.
8. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.

Treatment

• First step in an SVT episode — Vagal maneuvers: modified Valsalva—straining against a closed glottis for 15 seconds (approximately 40 mmHg) in a semi-recumbent position, immediately followed by laying the patient supine and elevating the legs to 45° for 15 seconds; carotid sinus massage—first auscultate for a carotid bruit, then apply unilateral carotid sinus pressure for 5–10 seconds.
• For acute termination of an SVT attack (first drug) — Adenosine: 6 mg rapid IV bolus (in 1–2 seconds), immediately followed by flushing with 20 mL physiological saline; If tachycardia does not stop within 1–2 minutes, 12 mg rapid IV bolus; 12 mg once more if necessary.
• Prophylaxis, rate control and symptom suppression (in low LVEF/heart failure only in stable and euvolemic patients; in this case, long-acting succinate form or bisoprolol is preferred; if non-selective beta blockers are used, switch to beta-1 selective) — Metoprolol (oral): immediate-release tartrate is started at 25 mg twice a day, gradually increasing as tolerated to a maximum of 200 mg per day, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Cardioselective alternative in cardiomyopathy — Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• If LVEF is normal and there is no heart failure, alternative prophylaxis — Verapamil (oral): immediate-release form is started at 40 mg 3–4 times a day, increased according to heart rate control; maintenance 120–480 mg per day, maximum 480 mg per day.
• Other than HCM, for rate control maintenance — Digoxin: oral maintenance 0.125–0.5 mg daily in 2 divided doses; The dose is adjusted according to the serum digoxin level.
• Rhythm control in a selected patient with preserved LVEF and no heart failure — Sotalol: 80 mg is started by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.
• Consider catheter ablation in refractory arrhythmia with individual risk–benefit assessment in an experienced center.

Note

• Do not use verapamil in LVEF < 40% or heart failure. Do not use diltiazem during pregnancy and breastfeeding.
• Avoid positive inotropes (digoxin, dobutamine) and hypovolemia, excessive diuresis, vasodilation and tachycardia in HCM.
• In ARVC, do not discontinue beta-blocker therapy, including sotalol, during pregnancy or the postpartum period; reprogram the ICD appropriately.
• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Use flecainide and sotalol only under the supervision of a specialist team, in selected patients and with close ECG monitoring. Do not use flecainide in structural heart disease, previous myocardial infarction or LVEF ≤ 40% (addition to beta-blocker, based on expert judgment in ARVC). Sotalol may be used with expert judgment in selected structural heart disease and ARVC; It is not a routine option in severe left ventricular dysfunction (LVEF < 40%) and is not used in decompensated heart failure.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Vagal maneuver: No pressure is applied to the eyeball.
• Adenosine: Given under continuous ECG recording; The initial dose is reduced to 3 mg in those receiving dipyridamole or carbamazepine, in those with heart transplantation and when given through the central vein; It is not given in bronchospasm or asthma, second-third degree AV block and sick sinus syndrome or symptomatic bradycardia (if there is no functional pacemaker); If advanced block develops with one dose, no additional dose is given.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Bisoprolol: Started only in stable and euvolemic patients.
• Verapamil (oral): Not administered in the presence of pre-excitation (WPW) or in patients with reduced LVEF. Postpartum, any dose increased during pregnancy should be re-evaluated.
• Verapamil (oral): Lowest effective dose used in pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.
• Digoxin: Not given in the presence of pre-excitation (WPW); Dosage adjustment may be required after birth.
• Digoxin: Maternal serum digoxin level is closely monitored during pregnancy; In later stages of pregnancy, higher doses may be required for therapeutic levels.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.

Approach

1. Document rhythm with 12-lead ECG; perform rhythm monitoring if necessary; evaluate electrolytes, thyroid function, complete blood count, and ECHO; Look for valve disease, cardiomyopathy, congenital heart disease, thyroid disease, and other systemic causes.
2. If there is more than one concomitant disease, apply the anticoagulation plan for valve disease or prosthesis, ventricular dysfunction and drug restrictions for cardiomyopathy together in the same management plan.
3. Control rhythm load early; Conduct maternal rhythm management together with fetal monitoring.
4. Individualize anticoagulation requirement according to maternal thromboembolic risk; Previous thromboembolism increases the risk.
5. If AF/flutter exceeds 48 hours or duration is unknown, provide at least 3 weeks of therapeutic anticoagulation before pharmacological or electrical cardioversion or initiate therapeutic anticoagulation and exclude left atrial thrombus by transesophageal ECHO; Maintain anticoagulation for at least 4 weeks after cardioversion. Do not delay shock in an unstable patient for this reason.
6. Put the birth and puerperium follow-up plan in writing.
7. Determine the mode of delivery according to obstetric indications; Isolated arrhythmia alone is not an indication for cesarean section.
8. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.
9. Avoid estrogen-containing combined hormonal contraception; Choose long-acting methods such as intrauterine device or progestin implant.

Treatment

• In acute rate control — Metoprolol: 2.5–5 mg IV over 2 minutes; If necessary, repeat every 5 minutes, maximum 15 mg in total.
• For rate control and maintenance of symptom suppression — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Alternative for rate control — Verapamil: 2.5–10 mg IV, slow bolus over 5 minutes; It can be repeated after 30 minutes if necessary.
• Alternative for rate control — Digoxin: 0.5 mg IV by slow injection over at least 5 minutes; additional dose of 0.25 mg every 6 hours if necessary; Total 8–12 µg/kg (calculated by lean body weight) and not exceeding 0.75–1.5 mg in 24 hours; If creatinine clearance is 15 mL/min or less, the dose is halved.
• Alternative for rate control maintenance — Digoxin: oral maintenance 0.125–0.5 mg daily divided into 2 doses; The dose is adjusted according to the serum digoxin level.
• If symptoms or rapid ventricular response persist despite rate control or if hemodynamics is impaired — Synchronized electrical cardioversion: initial energy on the biphasic device is 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• In pharmacological cardioversion — Flecainide: 2 mg/kg IV over at least 10 minutes (with a history of heart failure, the first dose is within 30 minutes); single bolus maximum 150 mg; It is given under continuous ECG monitoring, the injection is stopped when arrhythmia is checked; In severe renal impairment (creatinine clearance below 35 mL/min/1.73 m²), the dose is halved.
• In pharmacological cardioversion — Ibutilide: 0.01 mg/kg under 60 kg, 1 mg IV over 10 minutes for those weighing 60 kg or more; If the arrhythmia continues 10 minutes after the end of the first infusion, the same dose is given again in 10 minutes (maximum 2 doses in total); The infusion is stopped when the arrhythmia ends, sustained or non-sustained VT develops, or QT/QTc is significantly prolonged.
• In the absence of structural heart disease, in addition to beta-blockers for rhythm control — Flecainide: start at 50 mg orally every 12 hours (in ventricular arrhythmia, 50–100 mg every 12 hours); If necessary, increase each dose by 50 mg every 4 days at the earliest; Maximum daily dose is 300 mg in AF/flutter and SVT, 400 mg in ventricular arrhythmia; Every 12 hours, in divided doses every 8 hours if necessary.
• Rhythm control — Sotalol: start at 80 mg by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.
• If anticoagulation is required: generally choose therapeutic dose LMWH (enoxaparin based on weight, usually 1 mg/kg SC every 12 hours).
• Stop heparin before planned delivery: wait at least 12 hours after prophylactic LMWH, wait at least 24 hours after an intermediate or therapeutic dose; If there is no significant bleeding or significant risk of bleeding, restart 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
• Only a prophylactic dose of LMWH may be administered with the neuraxial catheter in place; remove the catheter at least 12 hours after the last prophylactic dose and at least 24 hours after the last therapeutic dose; Start prophylactic LMWH at least 12 hours after the intervention, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• In drug-resistant and poorly tolerated cavotricuspid isthmus-dependent (typical) atrial flutter, consider catheter ablation in an experienced center with a mapping system without fluoroscopy and preferably after the first trimester.

Note

• Do not use verapamil in LVEF < 40% or heart failure. Do not use diltiazem during pregnancy and breastfeeding.
• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Use flecainide and sotalol only under the supervision of a specialist team, in selected patients and with close ECG monitoring. Do not use flecainide in structural heart disease, previous myocardial infarction or LVEF ≤ 40% (addition to beta-blocker, based on expert judgment in ARVC). Sotalol may be used with expert judgment in selected structural heart disease and ARVC; It is not a routine option in severe left ventricular dysfunction (LVEF < 40%) and is not used in decompensated heart failure.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Do not use DOACs during pregnancy or breastfeeding; VKA (warfarin) is generally avoided during pregnancy except for mechanical valve and moderate to severe mitral stenosis.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Do not routinely plan ablation for AF during pregnancy; consider it exceptionally through a specialist multidisciplinary team for recurrent hemodynamically unstable AF that cannot be controlled with medication.
• Assess renal function before enoxaparin; if creatinine clearance is <30 mL/min, do not apply the standard regimens unchanged; reduce the dose according to renal function or consider UFH with the specialist team.
• Metoprolol: Not given IV in decompensated heart failure (electrical cardioversion is preferred).
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Verapamil: Used only in patients with preserved LVEF; may cause maternal hypotension; If possible, adenosine or beta blocker is preferred in SVT, and IV beta-1 selective blocker is priority in AF/flutter rate control; It is not given concurrently with IV beta blockers; It is not given in pre-excitation (WPW) AF/flutter, ventricular tachycardia and wide QRS tachycardia of unknown supraventricular origin.
• Digoxin: Not given in the presence of pre-excitation (WPW); Dosage adjustment may be required after birth.
• Digoxin: Maternal serum digoxin level is closely monitored during pregnancy; In later stages of pregnancy, higher doses may be required for therapeutic levels.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Flecainide: Not given in structural or ischemic heart disease. If there is no pre-excitation (WPW), it is used together with an AV node blocker such as a beta blocker against the risk of 1:1 AV conduction in atrial flutter; In WPW, no AV node blocker is added. After delivery, the increased dose during pregnancy is re-evaluated.
• Flecainide: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.
• Ibutilide: Hypokalemia and hypomagnesemia are first corrected; Other QT prolonging drugs are discontinued before and after; ECG is monitored continuously for at least 4 hours after the infusion and until QTc returns to the initial value. If arrhythmia occurs, it is monitored longer.
• Ibutilide: Experience in pregnancy is limited; It is avoided in the first trimester.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.

Approach

1. Document rhythm with 12-lead ECG; perform rhythm monitoring if necessary; Assess electrolytes, thyroid function, complete blood count, and ECHO.
2. If there is more than one concomitant disease, apply the anticoagulation plan for valve disease or prosthesis, ventricular dysfunction and drug restrictions for cardiomyopathy together in the same management plan.
3. Risk stratify with mWHO, CARPREG II (previous arrhythmia 3 points) and ZAHARA in congenital heart disease.
4. Plan close follow-up at a tertiary center and evaluate by a multidisciplinary committee; Perform regular ECG/Holter monitoring.
5. Prepare a written antenatal emergency plan; establish the intrapartum emergency algorithm and team role assignments in writing.
6. Monitor fetal growth for risk of preterm birth and fetal growth restriction; If the mother or father has congenital heart disease, discuss the risk of recurrence in the fetus and recommend fetal echocardiography at 18–22 weeks
7. Apply pharmacological treatment aggressively in congenital heart disease as arrhythmia may trigger decompensation.
8. AF in structural heart disease increases the risk of systemic embolism; individualize anticoagulation according to thromboembolic risk; In congenital heart disease, determine the strategy according to the lesion, history of thrombosis, oxygen saturation and ventricular function.
9. If AF/flutter exceeds 48 hours or duration is unknown, provide at least 3 weeks of therapeutic anticoagulation before pharmacological or electrical cardioversion or initiate therapeutic anticoagulation and exclude left atrial thrombus by transesophageal ECHO; Maintain anticoagulation for at least 4 weeks after cardioversion. Do not delay shock in an unstable patient for this reason.
10. Determine the mode of delivery according to obstetric indications; do not routinely perform cesarean delivery.
11. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.
12. Avoid estrogen-containing combined hormonal contraception; Choose long-acting methods such as intrauterine device or progestin implant.

Treatment

• In acute rate control — Metoprolol: 2.5–5 mg IV over 2 minutes; If necessary, repeat every 5 minutes, maximum 15 mg in total.
• For rate control and maintenance of symptom suppression — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Alternative for rate control — Verapamil: 2.5–10 mg IV, slow bolus over 5 minutes; It can be repeated after 30 minutes if necessary.
• Alternative for rate control — Digoxin: 0.5 mg IV by slow injection over at least 5 minutes; additional dose of 0.25 mg every 6 hours if necessary; Total 8–12 µg/kg (calculated by lean body weight) and not exceeding 0.75–1.5 mg in 24 hours; If creatinine clearance is 15 mL/min or less, the dose is halved.
• Alternative for rate control maintenance — Digoxin: oral maintenance 0.125–0.5 mg daily divided into 2 doses; The dose is adjusted according to the serum digoxin level.
• If symptoms or rapid ventricular response persist despite rate control or if hemodynamics is impaired — Synchronized electrical cardioversion: initial energy on the biphasic device is 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• Rhythm control in a selected patient with preserved LVEF and no heart failure — Sotalol: 80 mg is started by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.
• If anticoagulation is required: generally choose therapeutic dose LMWH (enoxaparin based on weight, usually 1 mg/kg SC every 12 hours).
• Stop heparin before planned delivery: wait at least 12 hours after prophylactic LMWH, wait at least 24 hours after an intermediate or therapeutic dose; If there is no significant bleeding or significant risk of bleeding, restart 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
• Only a prophylactic dose of LMWH may be administered with the neuraxial catheter in place; remove the catheter at least 12 hours after the last prophylactic dose and at least 24 hours after the last therapeutic dose; Start prophylactic LMWH at least 12 hours after the intervention, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• In drug-resistant and poorly tolerated cavotricuspid isthmus-dependent (typical) atrial flutter, consider catheter ablation in an experienced center with a mapping system without fluoroscopy and preferably after the first trimester.

Note

• Do not use verapamil in LVEF < 40% or heart failure. Do not use diltiazem during pregnancy and breastfeeding.
• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Use flecainide and sotalol only under the supervision of a specialist team, in selected patients and with close ECG monitoring. Do not use flecainide in structural heart disease, previous myocardial infarction or LVEF ≤ 40% (addition to beta-blocker, based on expert judgment in ARVC). Sotalol may be used with expert judgment in selected structural heart disease and ARVC; It is not a routine option in severe left ventricular dysfunction (LVEF < 40%) and is not used in decompensated heart failure.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Do not use DOACs during pregnancy or breastfeeding; VKA (warfarin) is generally avoided during pregnancy except for mechanical valve and moderate to severe mitral stenosis.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Do not routinely plan ablation for AF during pregnancy; consider it exceptionally through a specialist multidisciplinary team for recurrent hemodynamically unstable AF that cannot be controlled with medication.
• Assess renal function before enoxaparin; if creatinine clearance is <30 mL/min, do not apply the standard regimens unchanged; reduce the dose according to renal function or consider UFH with the specialist team.
• Metoprolol: Not given IV in decompensated heart failure (electrical cardioversion is preferred).
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Verapamil: Used only in patients with preserved LVEF; may cause maternal hypotension; If possible, adenosine or beta blocker is preferred in SVT, and IV beta-1 selective blocker is priority in AF/flutter rate control; It is not given concurrently with IV beta blockers; It is not given in pre-excitation (WPW) AF/flutter, ventricular tachycardia and wide QRS tachycardia of unknown supraventricular origin.
• Digoxin: Not given in the presence of pre-excitation (WPW); Dosage adjustment may be required after birth.
• Digoxin: Maternal serum digoxin level is closely monitored during pregnancy; In later stages of pregnancy, higher doses may be required for therapeutic levels.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.

Approach

1. Document rhythm with 12-lead ECG; perform rhythm monitoring if necessary; Assess electrolytes, thyroid function, complete blood count, and ECHO.
2. If there is more than one concomitant disease, apply the anticoagulation plan for valve disease or prosthesis, ventricular dysfunction and drug restrictions for cardiomyopathy together in the same management plan.
3. Provide cardiology–obstetrics co-management; evaluate by a multidisciplinary committee at a tertiary center; Closely monitor for decreased effort capacity, recurrent tachyarrhythmia, and tendency to decompensation.
4. Save LVEF and NYHA functional class. If LVEF < 30% or NYHA III–IV heart failure, consider mWHO IV; Discuss the maternal risk, continuation in a specialist center and, if legally and ethically appropriate, the option of terminating the pregnancy in the early period.
5. LVEF < 35% or if thrombus is present, therapeutic anticoagulation required; In other conditions, such as atrial arrhythmia, individualize anticoagulation according to thromboembolic risk.
6. If AF/flutter exceeds 48 hours or duration is unknown, provide at least 3 weeks of therapeutic anticoagulation before pharmacological or electrical cardioversion or initiate therapeutic anticoagulation and exclude left atrial thrombus by transesophageal ECHO; Maintain anticoagulation for at least 4 weeks after cardioversion. Do not delay shock in an unstable patient for this reason.
7. Monitor fetal growth with serial ultrasonography and fetal well-being with umbilical artery and middle cerebral artery Doppler.
8. Prepare a written birth plan at approximately week 32; Determine birth order emergency algorithm and team tasks.
9. Vaginal delivery is recommended for most cardiomyopathies; Caesarean section is preferred if there is obstetric indication, severe heart failure (LVEF < 30% and/or NYHA III–IV), uncontrolled arrhythmia, outflow tract obstruction ≥ 50 mmHg in HCM, or labor under VKA (warfarin).
10. Administer epidural analgesia, initiated early in labor and continued without interruption; Avoid excessive vasodilation in HCM; Use assisted vaginal birth in conjunction with cardiology based on individual risk assessment to shorten the second stage.
11. Intensify postpartum monitoring; plan proactive monitoring for recurrence in the first weeks and early check-up before discharge; teach warning signs and review antiarrhythmic therapy for breastfeeding compatibility.
12. Closely monitor patients with reduced myocardial reserve for pulmonary edema, hypoxia and cardiogenic shock, especially in the first 24–72 hours after birth.
13. Prioritize cardioversion for rhythm control in AF in HCM.

Treatment

• In acute rate control (unless decompensated heart failure) — Metoprolol: 2.5–5 mg IV over 2 minutes; If necessary, repeat every 5 minutes, maximum 15 mg in total.
• Alternative for acute rate control other than HCM — Digoxin: 0.5 mg IV by slow injection over at least 5 minutes; additional dose of 0.25 mg every 6 hours if necessary; Total 8–12 µg/kg (calculated by lean body weight) and not exceeding 0.75–1.5 mg in 24 hours; If creatinine clearance is 15 mL/min or less, the dose is halved.
• In low LVEF/heart failure only in stable and euvolemic patients; In this case, the long-acting form of succinate or bisoprolol is preferred; if using non-selective beta blocker, switch to beta-1 selective — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• Other than HCM, for rate control maintenance — Digoxin: oral maintenance 0.125–0.5 mg daily in 2 divided doses; The dose is adjusted according to the serum digoxin level.
• If LVEF is normal and there is no heart failure, alternative to rate control — Verapamil (oral): immediate-release form is started at 40 mg 3–4 times daily, increasing according to heart rate control; maintenance 120–480 mg per day, maximum 480 mg per day.
• If symptoms or rapid ventricular response persist despite rate control or if hemodynamics is impaired — Synchronized electrical cardioversion: initial energy on the biphasic device is 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• If anticoagulation is required: generally choose therapeutic dose LMWH (enoxaparin based on weight, usually 1 mg/kg SC every 12 hours).
• If there is documented intracardiac thrombus or LVEF < 35% in cardiomyopathy (including PPCM), therapeutic dose LMWH (enoxaparin): 1 mg/kg SC based on early pregnancy weight every 12 hours (if renal function is appropriate).
• If bromocriptine is used in PPCM (minimum prophylactic dose) — Enoxaparin (prophylactic): 40 mg SC once daily under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• When using bromocriptine in PPCM, if LVEF < 35%, intracardiac thrombus or AF with high thromboembolic risk, therapeutic dose LMWH (enoxaparin): 1 mg/kg SC every 12 hours according to early pregnancy weight.
• Stop heparin before planned delivery: wait at least 12 hours after prophylactic LMWH, wait at least 24 hours after an intermediate or therapeutic dose; If there is no significant bleeding or significant risk of bleeding, restart 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
• Only a prophylactic dose of LMWH may be administered with the neuraxial catheter in place; remove the catheter at least 12 hours after the last prophylactic dose and at least 24 hours after the last therapeutic dose; Start prophylactic LMWH at least 12 hours after the intervention, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• At birth, by slow infusion rather than rapid IV bolus — Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).

Note

• Avoid positive inotropes (digoxin, dobutamine) and hypovolemia, excessive diuresis, vasodilation and tachycardia in HCM.
• Do not use verapamil in LVEF < 40% or heart failure. Do not use diltiazem during pregnancy and breastfeeding.
• In ARVC, do not discontinue beta-blocker therapy, including sotalol, during pregnancy or the postpartum period; reprogram the ICD appropriately.
• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Do not use DOACs during pregnancy or breastfeeding; VKA (warfarin) is generally avoided during pregnancy except for mechanical valve and moderate to severe mitral stenosis.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• If HCM is accompanied by clinical AF/flutter, apply therapeutic anticoagulation regardless of thromboembolic risk score (therapeutic dose LMWH during pregnancy).
• Assess renal function before enoxaparin; if creatinine clearance is <30 mL/min, do not apply the standard regimens unchanged; reduce the dose according to renal function or consider UFH with the specialist team.
• Metoprolol: Not given IV in decompensated heart failure (electrical cardioversion is preferred).
• Digoxin: Not given in the presence of pre-excitation (WPW); Dosage adjustment may be required after birth.
• Digoxin: Maternal serum digoxin level is closely monitored during pregnancy; In later stages of pregnancy, higher doses may be required for therapeutic levels.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Bisoprolol: Started only in stable and euvolemic patients.
• Verapamil (oral): Not administered in the presence of pre-excitation (WPW) or in patients with reduced LVEF. Postpartum, any dose increased during pregnancy should be re-evaluated.
• Verapamil (oral): Lowest effective dose used in pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Classify moderate mitral stenosis as mWHO III and severe mitral stenosis as mWHO IV; In case of severe mitral stenosis, discuss the risk of the mother in the early period, the option of continuing in a specialist center and terminating the pregnancy if it is legally and ethically appropriate.
2. Monitor at the specialist center with the Pregnancy Heart Team; In mWHO III, do cardiology check-ups generally every 1–2 months and create a birth plan early.
3. Evaluate with 12-lead ECG, rhythm monitoring, electrolytes, thyroid functions, complete blood count and ECHO; Take into account that stenosis gradients increase during pregnancy.
4. If there is more than one concomitant disease, apply the anticoagulation plan for valve disease or prosthesis, ventricular dysfunction and drug restrictions for cardiomyopathy together in the same management plan.
5. Conduct maternal rhythm management in conjunction with fetal monitoring.
6. If AF/flutter exceeds 48 hours or duration is unknown, provide at least 3 weeks of therapeutic anticoagulation before pharmacological or electrical cardioversion or initiate therapeutic anticoagulation and exclude left atrial thrombus by transesophageal ECHO; Maintain anticoagulation for at least 4 weeks after cardioversion. Do not delay shock in an unstable patient for this reason.
7. Plan the birth at the reference centre; Prepare the birth plan in advance and share it with the whole team, perform a prenatal obstetric anesthesia evaluation and apply continuous telemetry during birth.
8. Plan vaginal delivery with appropriate analgesia and minimal Valsalva; Cesarean section is preferred in severe mitral stenosis and resistant heart failure.
9. Determine the frequency of postpartum check-ups according to symptoms; It may take up to 6 months for hemodynamic changes to improve.
10. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.
11. Avoid estrogen-containing combined hormonal contraception; Choose long-acting methods such as intrauterine device or progestin implant.

Treatment

• Basic treatment, acute rate control — Metoprolol: 2.5–5 mg IV over 2 minutes; If necessary, repeat every 5 minutes, maximum 15 mg in total.
• Basic treatment, maintenance — Metoprolol (oral): immediate-release tartrate start at 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Alternative for rate control — Verapamil: 2.5–10 mg IV, slow bolus over 5 minutes; It can be repeated after 30 minutes if necessary.
• Alternative for rate control — Digoxin: 0.5 mg IV by slow injection over at least 5 minutes; additional dose of 0.25 mg every 6 hours if necessary; Total 8–12 µg/kg (calculated by lean body weight) and not exceeding 0.75–1.5 mg in 24 hours; If creatinine clearance is 15 mL/min or less, the dose is halved.
• Alternative for rate control maintenance — Digoxin: oral maintenance 0.125–0.5 mg daily divided into 2 doses; The dose is adjusted according to the serum digoxin level.
• If symptoms or rapid ventricular response persist despite rate control or if hemodynamics is impaired — Synchronized electrical cardioversion: initial energy on the biphasic device is 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• If AF in mitral stenosis, left atrial thrombus, or previous embolism, administer full therapeutic dose anticoagulation: therapeutic dose LMWH (enoxaparin based on weight, usually 1 mg/kg SC every 12 hours) or VKA; Make the selection with the Pregnancy Heart Team based on gestational age, warfarin dose and the patient's informed preference.
• In heart failure that persists despite rate control — Furosemide (oral): 20–40 mg once a day is started; If the response is insufficient, the single dose is adjusted by doubling instead of giving the same dose more frequently; The new dose is given no earlier than 6–8 hours after the previous dose; usual dose 40–240 mg per day; Maximum total daily dose of 600 mg (up to 1000 mg in severe renal impairment).
• Valvuloplasty or valve replacement: only apply during pregnancy for symptoms resistant to medical treatment.
• Stop heparin before planned delivery: wait at least 12 hours after prophylactic LMWH, wait at least 24 hours after an intermediate or therapeutic dose; If there is no significant bleeding or significant risk of bleeding, restart 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
• Only a prophylactic dose of LMWH may be administered with the neuraxial catheter in place; remove the catheter at least 12 hours after the last prophylactic dose and at least 24 hours after the last therapeutic dose; Start prophylactic LMWH at least 12 hours after the intervention, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.

Note

• Do not use verapamil in LVEF < 40% or heart failure. Do not use diltiazem during pregnancy and breastfeeding.
• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Do not use DOACs during pregnancy or breastfeeding; VKA (warfarin) is generally avoided during pregnancy except for mechanical valve and moderate to severe mitral stenosis.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Assess renal function before enoxaparin; if creatinine clearance is <30 mL/min, do not apply the standard regimens unchanged; reduce the dose according to renal function or consider UFH with the specialist team.
• Metoprolol: Not given IV in decompensated heart failure (electrical cardioversion is preferred).
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Verapamil: Used only in patients with preserved LVEF; may cause maternal hypotension; If possible, adenosine or beta blocker is preferred in SVT, and IV beta-1 selective blocker is priority in AF/flutter rate control; It is not given concurrently with IV beta blockers; It is not given in pre-excitation (WPW) AF/flutter, ventricular tachycardia and wide QRS tachycardia of unknown supraventricular origin.
• Digoxin: Not given in the presence of pre-excitation (WPW); Dosage adjustment may be required after birth.
• Digoxin: Maternal serum digoxin level is closely monitored during pregnancy; In later stages of pregnancy, higher doses may be required for therapeutic levels.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Furosemide (oral): No breastfeeding difficulties have been reported with the low dose (20 mg/day) in breastfeeding.
• Furosemide (oral): Use with caution during pregnancy as excessive diuresis may reduce uterine blood flow and placental perfusion.

Approach

1. Perform cardiology evaluation at least once per trimester, more frequently if the clinical situation warrants; Plan multidisciplinary follow-up with experts experienced in heart disease and pregnancy.
2. Evaluate with 12-lead ECG, rhythm monitoring, electrolytes, thyroid functions, complete blood count and ECHO.
3. If there is more than one concomitant disease, apply the anticoagulation plan for valve disease or prosthesis, ventricular dysfunction and drug restrictions for cardiomyopathy together in the same management plan.
4. AF in bioprosthetic valve is an additional risk factor; Individualize anticoagulant selection based on maternal thromboembolic risk.
5. If AF/flutter exceeds 48 hours or duration is unknown, provide at least 3 weeks of therapeutic anticoagulation before pharmacological or electrical cardioversion or initiate therapeutic anticoagulation and exclude left atrial thrombus by transesophageal ECHO; Maintain anticoagulation for at least 4 weeks after cardioversion. Do not delay shock in an unstable patient for this reason.
6. Conduct maternal rhythm management in conjunction with fetal monitoring.
7. Plan the birth at the reference center; The peripartum antithrombotic plan should be determined by gynecology, anesthesia and hematology together, documented in writing and explained to the patient; Be aware of the risk of spinal epidural hematoma with neuraxial technique.
8. Plan vaginal delivery with appropriate analgesia and minimal Valsalva; Isolated arrhythmia is not an indication for cesarean section.
9. Determine the frequency of check-ups during puerperium according to symptoms; plan proactive monitoring and early check-up for recurrence; Teach warning signs at discharge and review antiarrhythmic therapy for breastfeeding compatibility.
10. Avoid estrogen-containing combined hormonal contraception; Choose long-acting methods such as intrauterine device or progestin implant.

Treatment

• Apply long-term anticoagulation: usually prefer therapeutic dose LMWH (enoxaparin based on weight, usually 1 mg/kg SC every 12 hours).
• Low-dose aspirin (75–100 mg/day): consider in antithrombotic plan for bioprosthetic valve; Let the expert team determine its use with anticoagulation, considering the risk of bleeding.
• Stop heparin before planned delivery: wait at least 12 hours after prophylactic LMWH, wait at least 24 hours after an intermediate or therapeutic dose; If there is no significant bleeding or significant risk of bleeding, restart 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
• Only a prophylactic dose of LMWH may be administered with the neuraxial catheter in place; remove the catheter at least 12 hours after the last prophylactic dose and at least 24 hours after the last therapeutic dose; Start prophylactic LMWH at least 12 hours after the intervention, therapeutic LMWH at least 24 hours after the procedure, and in any case at least 4 hours after catheter withdrawal.
• In acute rate control — Metoprolol: 2.5–5 mg IV over 2 minutes; If necessary, repeat every 5 minutes, maximum 15 mg in total.
• For rate control and maintenance of symptom suppression — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Alternative for rate control — Verapamil: 2.5–10 mg IV, slow bolus over 5 minutes; It can be repeated after 30 minutes if necessary.
• Alternative for rate control — Digoxin: 0.5 mg IV by slow injection over at least 5 minutes; additional dose of 0.25 mg every 6 hours if necessary; Total 8–12 µg/kg (calculated by lean body weight) and not exceeding 0.75–1.5 mg in 24 hours; If creatinine clearance is 15 mL/min or less, the dose is halved.
• Alternative for rate control maintenance — Digoxin: oral maintenance 0.125–0.5 mg daily divided into 2 doses; The dose is adjusted according to the serum digoxin level.
• If symptoms or rapid ventricular response persist despite rate control or if hemodynamics is impaired — Synchronized electrical cardioversion: initial energy on the biphasic device is 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• Rhythm control in a selected patient with preserved LVEF and no heart failure — Sotalol: 80 mg is started by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.

Note

• Do not use DOACs during pregnancy and breastfeeding.
• Do not use verapamil in LVEF < 40% or heart failure. Do not use diltiazem during pregnancy and breastfeeding.
• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Use flecainide and sotalol only under the supervision of a specialist team, in selected patients and with close ECG monitoring. Do not use flecainide in structural heart disease, previous myocardial infarction or LVEF ≤ 40% (addition to beta-blocker, based on expert judgment in ARVC). Sotalol may be used with expert judgment in selected structural heart disease and ARVC; It is not a routine option in severe left ventricular dysfunction (LVEF < 40%) and is not used in decompensated heart failure.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Assess renal function before enoxaparin; if creatinine clearance is <30 mL/min, do not apply the standard regimens unchanged; reduce the dose according to renal function or consider UFH with the specialist team.
• Metoprolol: Not given IV in decompensated heart failure (electrical cardioversion is preferred).
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Verapamil: Used only in patients with preserved LVEF; may cause maternal hypotension; If possible, adenosine or beta blocker is preferred in SVT, and IV beta-1 selective blocker is priority in AF/flutter rate control; It is not given concurrently with IV beta blockers; It is not given in pre-excitation (WPW) AF/flutter, ventricular tachycardia and wide QRS tachycardia of unknown supraventricular origin.
• Digoxin: Not given in the presence of pre-excitation (WPW); Dosage adjustment may be required after birth.
• Digoxin: Maternal serum digoxin level is closely monitored during pregnancy; In later stages of pregnancy, higher doses may be required for therapeutic levels.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.

Approach

1. Manage at a specialist center with a Pregnancy Heart Team; Have your cardiology check-up usually every 1-2 months and create your birth plan early.
2. Evaluate with 12-lead ECG, rhythm monitoring, electrolytes, thyroid functions, complete blood count and ECHO.
3. If there is more than one concomitant disease, apply the anticoagulation plan for valve disease or prosthesis, ventricular dysfunction and drug restrictions for cardiomyopathy together in the same management plan.
4. Conduct maternal rhythm management in conjunction with fetal monitoring.
5. If AF/flutter exceeds 48 hours or duration is unknown, provide at least 3 weeks of therapeutic anticoagulation before pharmacological or electrical cardioversion or initiate therapeutic anticoagulation and exclude left atrial thrombus by transesophageal ECHO; Maintain anticoagulation for at least 4 weeks after cardioversion. Do not delay shock in an unstable patient for this reason.
6. Plan the birth at a reference center with neonatal intensive care facilities; prepare the birth plan in advance and distribute it to the entire team; perform a prenatal obstetric anesthesia evaluation; Apply continuous telemetry during labor.
7. Develop the peripartum antithrombotic plan with the obstetrician, anesthesiologist, and hematologist, clearly document it, and explain it in detail to the patient.
8. Plan vaginal delivery with neuraxial analgesia if timed according to the anticoagulation schedule and there is no obstetric indication; Minimize Valsalva.
9. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.

Treatment

• AF/flutter is a risk factor for valve thrombosis with a mechanical valve. Apply anticoagulation according to the pregnancy stage by selecting 'Mechanical prosthetic valve' in the algorithm. In that selection, use the 1st-trimester option 'Warfarin ≤ 5 mg/day; risk factor for valve thrombosis present' or 'Warfarin > 5 mg/day'.
• Maintain therapeutic anticoagulation without interruption.
• If symptoms or rapid ventricular response persist despite rate control or if hemodynamics is impaired — Synchronized electrical cardioversion: initial energy on the biphasic device is 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• In acute rate control — Metoprolol: 2.5–5 mg IV over 2 minutes; If necessary, repeat every 5 minutes, maximum 15 mg in total.
• For rate control and maintenance of symptom suppression — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Alternative for rate control — Verapamil: 2.5–10 mg IV, slow bolus over 5 minutes; It can be repeated after 30 minutes if necessary.
• Alternative for rate control — Digoxin: 0.5 mg IV by slow injection over at least 5 minutes; additional dose of 0.25 mg every 6 hours if necessary; Total 8–12 µg/kg (calculated by lean body weight) and not exceeding 0.75–1.5 mg in 24 hours; If creatinine clearance is 15 mL/min or less, the dose is halved.
• Alternative for rate control maintenance — Digoxin: oral maintenance 0.125–0.5 mg daily divided into 2 doses; The dose is adjusted according to the serum digoxin level.
• In drug-resistant and poorly tolerated cavotricuspid isthmus-dependent (typical) atrial flutter, consider catheter ablation in an experienced center with a mapping system without fluoroscopy and preferably after the first trimester.

Note

• Prophylactic dose of LMWH is insufficient for mechanical valve.
• Do not use verapamil in LVEF < 40% or heart failure. Do not use diltiazem during pregnancy and breastfeeding.
• Do not use AV nodal blockers (beta blockers, verapamil, digoxin or adenosine) in pre-excited AF (WPW); if the patient is hemodynamically unstable, perform electrical cardioversion immediately.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Do not routinely plan ablation for AF during pregnancy; consider it exceptionally through a specialist multidisciplinary team for recurrent hemodynamically unstable AF that cannot be controlled with medication.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Metoprolol: Not given IV in decompensated heart failure (electrical cardioversion is preferred).
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Verapamil: Used only in patients with preserved LVEF; may cause maternal hypotension; If possible, adenosine or beta blocker is preferred in SVT, and IV beta-1 selective blocker is priority in AF/flutter rate control; It is not given concurrently with IV beta blockers; It is not given in pre-excitation (WPW) AF/flutter, ventricular tachycardia and wide QRS tachycardia of unknown supraventricular origin.
• Digoxin: Not given in the presence of pre-excitation (WPW); Dosage adjustment may be required after birth.
• Digoxin: Maternal serum digoxin level is closely monitored during pregnancy; In later stages of pregnancy, higher doses may be required for therapeutic levels.

Approach

1. Start treatment without waiting for detailed rhythm classification; Provide maternal stabilization first.
2. After stabilization, evaluate triggers and structural heart disease with 12-lead ECG, rhythm monitoring, electrolytes, thyroid functions, complete blood count and ECHO; Assess ventricular function, ischemic disease, cardiomyopathy, hereditary channelopathies, and family history of sudden cardiac death.
3. Rule out underlying peripartum cardiomyopathy in new-onset VT in the last 6 weeks of pregnancy or the first month postpartum.
4. Ventricular arrhythmia carries a high acute risk; Refer to a tertiary center with a low threshold and evaluate in a multidisciplinary committee.
5. Conduct maternal rhythm management in conjunction with fetal monitoring.
6. ICD indications do not change during pregnancy; If there is an indication, perform the procedure with a plan adapted to mother-fetus safety.
7. Determine in writing the birth order emergency algorithm and team task distribution; Maintain obstetric flexibility.
8. Determine the mode of delivery according to obstetric indications; Isolated arrhythmia alone is not an indication for cesarean section.
9. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.

Treatment

• Synchronized electrical cardioversion: initial energy on the biphasic device is 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• In pulseless VT/VF — Defibrillation: manufacturer's recommended energy on a biphasic device (initial 120–200 J), highest device energy if unknown; subsequent shocks with the same or higher energy; 360 J in monophasic device; The pads are placed anterolaterally, and the lateral pad is placed under or next to the breast tissue.
• If there is no pulse (cardiac arrest in pregnancy): immediately initiate high-quality cardiopulmonary resuscitation (CPR) and cardiac arrest algorithm; if the fundus is at or above the umbilicus, perform continuous manual left lateral uterine displacement with chest compression; Start resuscitative birth preparation at the diagnosis of arrest; If spontaneous circulation does not return with standard resuscitation, aim to complete the birth at the arrest site within the first 5 minutes.
• In polymorphic VT due to prolonged QT / torsades de pointes with a pulse (discontinue instigating drugs, restore potassium) — Magnesium sulfate: 1–2 g IV over 15 minutes; If there is no response or torsades de pointes recurs, repeat up to a total of 4 g in 1 hour; followed by 0.5–1 g/h IV infusion if necessary.
• In pulseless torsades de pointes, with defibrillation: magnesium sulfate 2 g IV/IO over at least 1–2 minutes; if ineffective, 2 g bolus up to 2 more times (maximum 6 g total).
• In emergency control of ventricular arrhythmia (advanced center) — Lidocaine: 1–1.5 mg/kg IV bolus, at a rate of 25–50 mg/min; additional bolus of 0.5–0.75 mg/kg every 5–10 minutes if necessary; Cumulative dose in one hour is up to 3 mg/kg and 300 mg; maintenance 1–4 mg/min IV infusion.
• In the absence of prolonged QT and torsade, emergency control of ventricular arrhythmia (in advanced center) — Procainamide: 15 mg/kg IV loading over at least 30 minutes and with an infusion rate not exceeding 50 mg/min (total loading not more than 17 mg/kg); followed by 1–4 mg/min IV infusion.
• In life-threatening refractory VT/VF in the absence of prolonged QT and torsades — Amiodarone: 150 mg IV over 10 minutes (may be repeated if arrhythmia recurs); followed by 1 mg/min IV infusion for 6 hours, then 0.5 mg/min for 18 hours; 300 mg IV/IO bolus in cardiac arrest, second dose 150 mg if necessary.

Note

• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Defibrillation: During pregnancy, the energy is the same as in non-pregnancy; if the fundus is at or above the umbilicus, manual left lateral uterine displacement is performed with chest compressions; Once cardiac arrest is diagnosed, external and internal fetal monitors are removed; Resuscitation and shock are not delayed for fetal assessment, fetal monitoring, or removal of monitors.
• Magnesium sulfate: If the patellar reflex disappears or the serum level exceeds 6 mEq/L, the infusion is discontinued.
• Lidocaine: All lidocaine doses, including lidocaine given for regional anesthesia, are included in the total dose.
• Procainamide: Stop loading if arrhythmia is suppressed, hypotension develops, or QRS duration is prolonged by more than 50%; It is avoided in prolonged QT and heart failure.
• Procainamide: Uterine irritability and preterm labor have been reported with IV use during pregnancy.
• Amiodarone: Avoided during pregnancy due to risk of fetal adverse effects; It is used only in life-threatening arrhythmia that cannot be controlled with other treatments; If administered, the fetus is monitored for bradycardia, growth restriction, and thyroid function.

Approach

1. Document rhythm with 12-lead ECG; perform rhythm monitoring if necessary; Assess electrolytes, thyroid function, complete blood count, and ECHO.
2. Assess ventricular function, ischemic disease, cardiomyopathy, hereditary channelopathies, and family history of sudden cardiac death.
3. Rule out underlying peripartum cardiomyopathy in new-onset VT in the last 6 weeks of pregnancy or the first month postpartum.
4. Ventricular arrhythmia carries a high acute risk; Refer to a tertiary center with a low threshold and evaluate in a multidisciplinary committee.
5. Conduct maternal rhythm management in conjunction with fetal monitoring.
6. Determine in writing the birth order emergency algorithm and team task distribution; Maintain obstetric flexibility.
7. Determine the mode of delivery according to obstetric indications; Isolated arrhythmia alone is not an indication for cesarean section.
8. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.

Treatment

• Also immediately in stable sustained VT — Synchronized electrical cardioversion: initial energy in the biphasic device 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after a shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• In polymorphic VT due to prolonged QT / torsades de pointes with a pulse (discontinue instigating drugs, restore potassium) — Magnesium sulfate: 1–2 g IV over 15 minutes; If there is no response or torsades de pointes recurs, repeat up to a total of 4 g in 1 hour; followed by 0.5–1 g/h IV infusion if necessary.
• If cardioversion cannot be performed immediately (drug of choice; in advanced center; in the absence of prolonged QT and torsade) — Procainamide: 15 mg/kg IV loading over at least 30 minutes and the infusion rate not to exceed 50 mg/min (total loading not more than 17 mg/kg); followed by 1–4 mg/min IV infusion.
• If cardioversion cannot be performed immediately (in advanced center) — Lidocaine: 1–1.5 mg/kg IV bolus, at a rate of 25–50 mg/min; additional bolus of 0.5–0.75 mg/kg every 5–10 minutes if necessary; Cumulative dose in one hour is up to 3 mg/kg and 300 mg; maintenance 1–4 mg/min IV infusion.
• In idiopathic outflow tract VT — Metoprolol: 2.5–5 mg IV over 2 minutes; If necessary, repeat every 5 minutes, maximum 15 mg in total.
• Alternative in idiopathic outflow tract VT — Adenosine: 6 mg rapid IV bolus (over 1–2 seconds), immediately followed by flushing with 20 mL saline; If tachycardia does not stop within 1–2 minutes, 12 mg rapid IV bolus; 12 mg once more if necessary.
• In expertly diagnosed idiopathic fascicular VT (if LVEF is preserved) — Verapamil: 2.5–10 mg IV, slow bolus over 5 minutes; It can be repeated after 30 minutes if necessary.
• For symptom suppression — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Rhythm control in a selected patient with preserved LVEF and no heart failure — Sotalol: 80 mg is started by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.
• In the absence of structural heart disease, in rhythm control — Flecainide: start at 50 mg orally every 12 hours (in ventricular arrhythmia, 50–100 mg every 12 hours); If necessary, increase each dose by 50 mg every 4 days at the earliest; Maximum daily dose is 300 mg in AF/flutter and SVT, 400 mg in ventricular arrhythmia; Every 12 hours, in divided doses every 8 hours if necessary.

Note

• Use flecainide and sotalol only under the supervision of a specialist team, in selected patients and with close ECG monitoring. Do not use flecainide in structural heart disease, previous myocardial infarction or LVEF ≤ 40% (addition to beta-blocker, based on expert judgment in ARVC). Sotalol may be used with expert judgment in selected structural heart disease and ARVC; It is not a routine option in severe left ventricular dysfunction (LVEF < 40%) and is not used in decompensated heart failure.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Magnesium sulfate: If the patellar reflex disappears or the serum level exceeds 6 mEq/L, the infusion is discontinued.
• Procainamide: Stop loading if arrhythmia is suppressed, hypotension develops, or QRS duration is prolonged by more than 50%; It is avoided in prolonged QT and heart failure.
• Procainamide: Uterine irritability and preterm labor have been reported with IV use during pregnancy.
• Lidocaine: All lidocaine doses, including lidocaine given for regional anesthesia, are included in the total dose.
• Metoprolol: Not given IV in decompensated heart failure (electrical cardioversion is preferred).
• Adenosine: Given under continuous ECG recording; The initial dose is reduced to 3 mg in those receiving dipyridamole or carbamazepine, in those with heart transplantation and when given through the central vein; It is not given in bronchospasm or asthma, second-third degree AV block and sick sinus syndrome or symptomatic bradycardia (if there is no functional pacemaker); If advanced block develops with one dose, no additional dose is given.
• Verapamil: Used only in patients with preserved LVEF; may cause maternal hypotension; If possible, adenosine or beta blocker is preferred in SVT, and IV beta-1 selective blocker is priority in AF/flutter rate control; It is not given concurrently with IV beta blockers; It is not given in pre-excitation (WPW) AF/flutter, ventricular tachycardia and wide QRS tachycardia of unknown supraventricular origin.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.
• Flecainide: Not given in structural or ischemic heart disease. If there is no pre-excitation (WPW), it is used together with an AV node blocker such as a beta blocker against the risk of 1:1 AV conduction in atrial flutter; In WPW, no AV node blocker is added. After delivery, the increased dose during pregnancy is re-evaluated.
• Flecainide: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.

Approach

1. Plan close follow-up at a tertiary center and evaluate by a multidisciplinary committee; Perform regular ECG/Holter monitoring.
2. Risk stratify with mWHO, CARPREG II (previous arrhythmia 3 points) and ZAHARA in congenital heart disease.
3. Prepare a written antenatal emergency plan; establish the intrapartum emergency algorithm and team role assignments in writing.
4. Consider the need for electrophysiology consultation.
5. Monitor fetal growth for risk of preterm birth and fetal growth restriction; If the mother or father has congenital heart disease, discuss the risk of recurrence in the fetus and recommend fetal echocardiography at 18–22 weeks
6. Apply pharmacological treatment aggressively in congenital heart disease as arrhythmia may trigger decompensation.
7. ICD indications do not change during pregnancy; If there is an indication, perform the procedure with a plan adapted to mother-fetus safety.
8. Determine the mode of delivery according to obstetric indications; do not routinely perform cesarean delivery.
9. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.

Treatment

• Beta blocker required — Metoprolol (oral): immediate-release tartrate start at 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Rhythm control in a selected patient with preserved LVEF and no heart failure — Sotalol: 80 mg is started by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.
• Consider catheter ablation in refractory arrhythmia with individual risk–benefit assessment in an experienced center.
• If hemodynamically unstable — Synchronized electrical cardioversion: initial energy on biphasic device 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• In pulseless VT/VF — Defibrillation: manufacturer's recommended energy on a biphasic device (initial 120–200 J), highest device energy if unknown; subsequent shocks with the same or higher energy; 360 J in monophasic device; The pads are placed anterolaterally, and the lateral pad is placed under or next to the breast tissue.
• If there is no pulse (cardiac arrest in pregnancy): immediately initiate high-quality cardiopulmonary resuscitation (CPR) and cardiac arrest algorithm; if the fundus is at or above the umbilicus, perform continuous manual left lateral uterine displacement with chest compression; Start resuscitative birth preparation at the diagnosis of arrest; If spontaneous circulation does not return with standard resuscitation, aim to complete the birth at the arrest site within the first 5 minutes.

Note

• Do not use atenolol routinely; Choose a beta blocker with a safer profile.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Use flecainide and sotalol only under the supervision of a specialist team, in selected patients and with close ECG monitoring. Do not use flecainide in structural heart disease, previous myocardial infarction or LVEF ≤ 40% (addition to beta-blocker, based on expert judgment in ARVC). Sotalol may be used with expert judgment in selected structural heart disease and ARVC; It is not a routine option in severe left ventricular dysfunction (LVEF < 40%) and is not used in decompensated heart failure.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Defibrillation: During pregnancy, the energy is the same as in non-pregnancy; if the fundus is at or above the umbilicus, manual left lateral uterine displacement is performed with chest compressions; Once cardiac arrest is diagnosed, external and internal fetal monitors are removed; Resuscitation and shock are not delayed for fetal assessment, fetal monitoring, or removal of monitors.

Approach

1. Provide cardiology–obstetrics co-management; evaluate by a multidisciplinary committee at a tertiary center; closely monitor for decreased effort capacity, recurrent tachyarrhythmia, and tendency to decompensation; Perform regular ECG/Holter monitoring.
2. Save LVEF and NYHA functional class. If LVEF < 30% or NYHA III–IV heart failure, consider mWHO IV; Discuss the maternal risk, continuation in a specialist center and, if legally and ethically appropriate, the option of terminating the pregnancy in the early period.
3. LVEF < 35% or if thrombus is present, therapeutic anticoagulation required; In other conditions, such as atrial arrhythmia, individualize anticoagulation according to thromboembolic risk.
4. ICD indications do not change during pregnancy; If there is an indication, perform the procedure with a plan adapted to mother-fetus safety.
5. Monitor fetal growth with serial ultrasonography and fetal well-being with umbilical artery and middle cerebral artery Doppler.
6. Prepare a written birth plan at approximately week 32; Determine birth order emergency algorithm and team tasks.
7. Vaginal delivery is recommended for most cardiomyopathies; Caesarean section is preferred if there is obstetric indication, severe heart failure (LVEF < 30% and/or NYHA III–IV), uncontrolled arrhythmia, outflow tract obstruction ≥ 50 mmHg in HCM, or labor under VKA (warfarin).
8. Administer epidural analgesia, initiated early in labor and continued without interruption; Avoid excessive vasodilation in HCM; Use assisted vaginal birth in conjunction with cardiology based on individual risk assessment to shorten the second stage.
9. Intensify postpartum monitoring; plan proactive monitoring for recurrence in the first weeks and early check-up before discharge; teach warning signs and review antiarrhythmic therapy for breastfeeding compatibility.
10. Closely monitor patients with reduced myocardial reserve for pulmonary edema, hypoxia and cardiogenic shock, especially in the first 24–72 hours after birth.

Treatment

• In low LVEF/heart failure only in stable and euvolemic patients; In this case, the long-acting form of succinate or bisoprolol is preferred; if using non-selective beta blocker, switch to beta-1 selective — Metoprolol (oral): start with immediate-release tartrate 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Bisoprolol: Start at 1.25 mg once daily; The target is 10 mg once a day, doubling the dose every 1–2 weeks.
• In ARVC, if there is no left ventricular systolic dysfunction, first-line antiarrhythmic in addition to beta-blocker — Flecainide: oral 50 mg every 12 hours is started (50–100 mg every 12 hours in ventricular arrhythmia); If necessary, increase each dose by 50 mg every 4 days at the earliest; Maximum daily dose is 300 mg in AF/flutter and SVT, 400 mg in ventricular arrhythmia; Every 12 hours, in divided doses every 8 hours if necessary.
• If there is documented intracardiac thrombus or LVEF < 35% in cardiomyopathy (including PPCM), therapeutic dose LMWH (enoxaparin): 1 mg/kg SC based on early pregnancy weight every 12 hours (if renal function is appropriate).
• If bromocriptine is used in PPCM (minimum prophylactic dose) — Enoxaparin (prophylactic): 40 mg SC once daily under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• When using bromocriptine in PPCM, if LVEF < 35%, intracardiac thrombus or AF with high thromboembolic risk, therapeutic dose LMWH (enoxaparin): 1 mg/kg SC every 12 hours according to early pregnancy weight.
• If hemodynamically unstable — Synchronized electrical cardioversion: initial energy on biphasic device 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• In pulseless VT/VF — Defibrillation: manufacturer's recommended energy on a biphasic device (initial 120–200 J), highest device energy if unknown; subsequent shocks with the same or higher energy; 360 J in monophasic device; The pads are placed anterolaterally, and the lateral pad is placed under or next to the breast tissue.
• If there is no pulse (cardiac arrest in pregnancy): immediately initiate high-quality cardiopulmonary resuscitation (CPR) and cardiac arrest algorithm; if the fundus is at or above the umbilicus, perform continuous manual left lateral uterine displacement with chest compression; Start resuscitative birth preparation at the diagnosis of arrest; If spontaneous circulation does not return with standard resuscitation, aim to complete the birth at the arrest site within the first 5 minutes.
• At birth, by slow infusion rather than rapid IV bolus — Oxytocin: 2 IU immediately after birth, slow IV infusion over 10 minutes; followed by 12 mU/min for 4 hours (10 IU oxytocin in 500 mL physiological saline, 36 mL/hour).

Note

• Use flecainide and sotalol only under the supervision of a specialist team, in selected patients and with close ECG monitoring. Do not use flecainide in structural heart disease, previous myocardial infarction or LVEF ≤ 40% (addition to beta-blocker, based on expert judgment in ARVC). Sotalol may be used with expert judgment in selected structural heart disease and ARVC; It is not a routine option in severe left ventricular dysfunction (LVEF < 40%) and is not used in decompensated heart failure.
• In ARVC, do not discontinue beta-blocker therapy, including sotalol, during pregnancy or the postpartum period; reprogram the ICD appropriately.
• Avoid positive inotropes (digoxin, dobutamine) and hypovolemia, excessive diuresis, vasodilation and tachycardia in HCM.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Assess renal function before enoxaparin; if creatinine clearance is <30 mL/min, do not apply the standard regimens unchanged; reduce the dose according to renal function or consider UFH with the specialist team.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Bisoprolol: Started only in stable and euvolemic patients.
• Flecainide: Not given in structural or ischemic heart disease. If there is no pre-excitation (WPW), it is used together with an AV node blocker such as a beta blocker against the risk of 1:1 AV conduction in atrial flutter; In WPW, no AV node blocker is added. After delivery, the increased dose during pregnancy is re-evaluated.
• Flecainide: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Defibrillation: During pregnancy, the energy is the same as in non-pregnancy; if the fundus is at or above the umbilicus, manual left lateral uterine displacement is performed with chest compressions; Once cardiac arrest is diagnosed, external and internal fetal monitors are removed; Resuscitation and shock are not delayed for fetal assessment, fetal monitoring, or removal of monitors.
• Oxytocin: Slow infusion is used instead of rapid bolus.

Approach

1. Perform further rhythm evaluation and consider genetic counseling.
2. Assess ventricular function, ischemic disease, cardiomyopathy, hereditary channelopathies, and family history of sudden cardiac death.
3. Refer to a tertiary center with a low threshold and evaluate by a multidisciplinary committee; Assess the need for electrophysiology consultation.
4. ICD indications do not change during pregnancy; If there is an indication, perform the procedure with a plan adapted to mother-fetus safety.
5. Prepare an individualized birth-puerperium plan; Determine the intrapartum emergency algorithm and team tasks in writing.
6. Conduct maternal rhythm management in conjunction with fetal monitoring.
7. Determine the mode of delivery according to obstetric indications; Isolated arrhythmia alone is not an indication for cesarean section.
8. Proactively monitor for recurrence during the first postpartum weeks; Schedule early check-ups before discharge, teach warning signs, and review antiarrhythmic therapy for breastfeeding compatibility.

Treatment

• If hemodynamically unstable — Synchronized electrical cardioversion: initial energy on biphasic device 200 J in AF and atrial flutter, 100 J in narrow QRS tachycardia and monomorphic VT (unsynchronized high-energy shock in polymorphous VT); pads are placed sterno-apically or antero-posteriorly, away from the breast tissue; Sedation is applied when possible (anesthesia is preferred if anesthesia service is available); Because the device often returns to asynchronous mode after the shock, synchronous mode is reactivated before each new shock; If synchronization is delayed and the situation is critical, non-synchronous shock is immediately applied.
• In pulseless VT/VF — Defibrillation: manufacturer's recommended energy on a biphasic device (initial 120–200 J), highest device energy if unknown; subsequent shocks with the same or higher energy; 360 J in monophasic device; The pads are placed anterolaterally, and the lateral pad is placed under or next to the breast tissue.
• If there is no pulse (cardiac arrest in pregnancy): immediately initiate high-quality cardiopulmonary resuscitation (CPR) and cardiac arrest algorithm; if the fundus is at or above the umbilicus, perform continuous manual left lateral uterine displacement with chest compression; Start resuscitative birth preparation at the diagnosis of arrest; If spontaneous circulation does not return with standard resuscitation, aim to complete the birth at the arrest site within the first 5 minutes.
• In polymorphic VT due to prolonged QT / torsades de pointes with a pulse (discontinue instigating drugs, restore potassium) — Magnesium sulfate: 1–2 g IV over 15 minutes; If there is no response or torsades de pointes recurs, repeat up to a total of 4 g in 1 hour; followed by 0.5–1 g/h IV infusion if necessary.
• In pulseless torsades de pointes, with defibrillation: magnesium sulfate 2 g IV/IO over at least 1–2 minutes; if ineffective, 2 g bolus up to 2 more times (maximum 6 g total).
• In emergency control of ventricular arrhythmia (advanced center) — Lidocaine: 1–1.5 mg/kg IV bolus, at a rate of 25–50 mg/min; additional bolus of 0.5–0.75 mg/kg every 5–10 minutes if necessary; Cumulative dose in one hour is up to 3 mg/kg and 300 mg; maintenance 1–4 mg/min IV infusion.
• In the absence of prolonged QT and torsade, emergency control of ventricular arrhythmia (in advanced center) — Procainamide: 15 mg/kg IV loading over at least 30 minutes and with an infusion rate not exceeding 50 mg/min (total loading not more than 17 mg/kg); followed by 1–4 mg/min IV infusion.
• Beta blocker required — Metoprolol (oral): immediate-release tartrate start at 25 mg twice daily, gradually increasing as tolerated, to a maximum of 200 mg daily, divided into 2–4 doses; Long-acting succinate is started at 25-50 mg once a day, gradually increasing as tolerated, to a maximum of 200 mg per day, divided into 1-2 doses.
• Alternative to beta-blocker in the prevention of idiopathic outflow tract VT (if LVEF is preserved) — Verapamil (oral): immediate-release form started at 40 mg 3–4 times daily, increased according to heart rate control; maintenance 120–480 mg per day, maximum 480 mg per day.
• If beta-blocker or verapamil are ineffective in idiopathic outflow tract VT — Flecainide: start at 50 mg orally every 12 hours (50–100 mg every 12 hours in ventricular arrhythmia); If necessary, increase each dose by 50 mg every 4 days at the earliest; Maximum daily dose is 300 mg in AF/flutter and SVT, 400 mg in ventricular arrhythmia; Every 12 hours, in divided doses every 8 hours if necessary.
• If beta blocker or verapamil are ineffective in idiopathic outflow tract VT, if initial QTc ≤ 450 ms — Sotalol: start at 80 mg by calculating creatinine clearance; Dosing range depends on creatinine clearance: ≥60 mL/min every 12 hours, 30–59 mL/min every 24 hours, 10–29 mL/min every 36–48 hours, not used at <10 mL/min; If QTc remains below 500 ms, increase every 3 days at the earliest to 120–160 mg per dose; maintenance 160–320 mg per day; If QTc increases to 500 ms or above, the dose is reduced, the dose interval is extended, or the drug is discontinued.
• Consider catheter ablation in refractory arrhythmia with individual risk–benefit assessment in an experienced center.

Note

• Use flecainide and sotalol only under the supervision of a specialist team, in selected patients and with close ECG monitoring. Do not use flecainide in structural heart disease, previous myocardial infarction or LVEF ≤ 40% (addition to beta-blocker, based on expert judgment in ARVC). Sotalol may be used with expert judgment in selected structural heart disease and ARVC; It is not a routine option in severe left ventricular dysfunction (LVEF < 40%) and is not used in decompensated heart failure.
• Do not use atenolol routinely; Choose a beta blocker with a safer profile.
• Monitor fetal growth and fetal bradycardia on beta blocker therapy. If the mother used beta blockers, monitor the newborn for bradycardia and hypoglycemia.
• Avoid amiodarone due to risk of fetal toxicity; Use only in life-threatening refractory arrhythmia.
• Synchronized electrical cardioversion: The energy during pregnancy is the same as in non-pregnancy; The procedure is not delayed due to concerns about harm to the fetus; If the fetal viability limit is exceeded, the fetal heart rate is monitored after the procedure and it is preferred to perform the procedure in a center where emergency cesarean section can be performed.
• Defibrillation: During pregnancy, the energy is the same as in non-pregnancy; if the fundus is at or above the umbilicus, manual left lateral uterine displacement is performed with chest compressions; Once cardiac arrest is diagnosed, external and internal fetal monitors are removed; Resuscitation and shock are not delayed for fetal assessment, fetal monitoring, or removal of monitors.
• Magnesium sulfate: If the patellar reflex disappears or the serum level exceeds 6 mEq/L, the infusion is discontinued.
• Lidocaine: All lidocaine doses, including lidocaine given for regional anesthesia, are included in the total dose.
• Procainamide: Stop loading if arrhythmia is suppressed, hypotension develops, or QRS duration is prolonged by more than 50%; It is avoided in prolonged QT and heart failure.
• Procainamide: Uterine irritability and preterm labor have been reported with IV use during pregnancy.
• Metoprolol (oral): Do not start or increase the dose in decompensated heart failure; It is not used in second-third degree AV block, sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia and cardiogenic shock. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Verapamil (oral): Not administered in the presence of pre-excitation (WPW) or in patients with reduced LVEF. Postpartum, any dose increased during pregnancy should be re-evaluated.
• Verapamil (oral): Lowest effective dose used in pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.
• Flecainide: Not given in structural or ischemic heart disease. If there is no pre-excitation (WPW), it is used together with an AV node blocker such as a beta blocker against the risk of 1:1 AV conduction in atrial flutter; In WPW, no AV node blocker is added. After delivery, the increased dose during pregnancy is re-evaluated.
• Flecainide: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels.
• Sotalol: Do not start if baseline QTc is greater than 450 ms; starting, re-starting and increasing the dose are done in a center with continuous ECG monitoring and resuscitation facilities, while starting, the patient is monitored in the hospital for at least 3 days; Proarrhythmia may develop with each dose increase; potassium and magnesium are kept within normal range before starting and throughout treatment (do not start if serum potassium <4 mEq/L); It is not used in asthma or bronchospastic disease, sinus bradycardia <50/min while awake, second-third degree AV block (if there is no functional pacemaker), sick sinus syndrome, congenital or acquired long QT syndrome, cardiogenic shock and decompensated heart failure; Concomitant use with amiodarone and other QT prolonging antiarrhythmics is avoided. After delivery, the increased dose during pregnancy is re-evaluated.
• Sotalol: The lowest effective dose is used during pregnancy; In later stages of pregnancy, higher doses may be required to achieve therapeutic serum levels. Fetal growth is monitored due to the beta blocker effect.

Approach

1. Monitor maternal and fetal growth closely for progression to preeclampsia; Systematically inquire about headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and sudden increase in edema.
2. Evaluate for proteinuria (≥300 mg in 24-hour urine, spot protein/creatinine ratio ≥0.3, or 2+ on dipstick if quantitative measurement is not available) and organ dysfunction with complete blood count and platelets, creatinine, AST/ALT, and bilirubin.
3. If thrombocytopenia, creatinine increase, transaminase elevation, pulmonary edema, new unexplained headache or visual symptoms develop, consider the diagnosis of preeclampsia even without proteinuria.
4. Measure BP with correct technique; If systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg, confirm by measuring again in 15 minutes; if persistent, initiate emergency treatment with IV labetalol, IV hydralazine, or oral immediate-release nifedipine as soon as possible, no later than 30–60 minutes; Apply the 'Acute severe hypertension' selection in the algorithm for doses and repeat intervals.
5. Plan delivery at 37+0 weeks and later (labor induction is a suitable option); Determine the type of delivery according to the gestational age, cervix status, fetal presentation, fetal well-being and obstetric indications.
6. Closely monitor BP during the first week postpartum (may rise again in the first days); Assess the risk of VTE (hypertension and caesarean section are risk factors) and individualize thromboprophylaxis according to risk stratification.
7. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; Include BP control, weight management, smoking cessation, lipid profile, glucose metabolism and kidney function in the long-term follow-up plan.

Treatment

• Oral antihypertensive therapy: start when systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg.
• Labetalol (oral): Start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• Metoprolol (oral): start with immediate-release tartrate 50 mg twice daily, gradually increasing according to response; The usual dose during pregnancy is 100 mg twice a day; maximum 200 mg daily, divided into 2 doses; Long-acting succinate is started at 25–100 mg once a day, up to 200 mg once a day.
• Nifedipine (long-acting, oral): Start at 30–60 mg once daily and increase at intervals of 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Methyldopa (oral): Start at 250 mg 2–3 times a day, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.

Note

• Avoid ACE inhibitors, angiotensin receptor blockers, and other RAAS-suppressing agents.
• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Metoprolol (oral): Not used in second-third degree AV block and sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia, cardiogenic shock and overt or decompensated heart failure; If the treatment is to be discontinued, the dose should be reduced over 1-2 weeks. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. Monitor maternal and fetal growth closely for progression to preeclampsia; Systematically inquire about headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and sudden increase in edema.
2. Evaluate for proteinuria (≥300 mg in 24-hour urine, spot protein/creatinine ratio ≥0.3, or 2+ on dipstick if quantitative measurement is not available) and organ dysfunction with complete blood count and platelets, creatinine, AST/ALT, and bilirubin.
3. If thrombocytopenia, creatinine increase, transaminase elevation, pulmonary edema, new unexplained headache or visual symptoms develop, consider the diagnosis of preeclampsia even without proteinuria; Use the sFlt-1/PlGF ratio to assess the likelihood of preeclampsia and the short-term risk of progression in selected cases, but not to make or exclude the diagnosis.
4. Consider outpatient follow-up only in selected patients who are asymptomatic, have stable maternal and fetal conditions, comply with frequent check-ups, have access to hospital, and have reliable home BP measurement.
5. Measure BP with correct technique; If systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg, confirm by measuring again in 15 minutes; if persistent, initiate emergency treatment with IV labetalol, IV hydralazine, or oral immediate-release nifedipine as soon as possible, no later than 30–60 minutes; apply the 'Acute severe hypertension' selection in the algorithm for doses and repeat intervals; If severe hypertension or organ dysfunction develops, reorganize management on the same basis as for preeclampsia.
6. If no serious findings develop and the mother-fetus condition remains stable, plan the birth for 37+0 weeks and later; Determine the type of delivery according to the gestational age, cervix status, fetal presentation, fetal well-being and obstetric indications.
7. Closely monitor BP during the first week postpartum (may rise again in the first days); Assess the risk of VTE (hypertension and caesarean section are risk factors) and individualize thromboprophylaxis according to risk stratification.
8. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; Include BP control, weight management, smoking cessation, lipid profile, glucose metabolism and kidney function in the long-term follow-up plan.

Treatment

• Oral antihypertensive therapy: start when systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg.
• Labetalol (oral): Start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• Metoprolol (oral): start with immediate-release tartrate 50 mg twice daily, gradually increasing according to response; The usual dose during pregnancy is 100 mg twice a day; maximum 200 mg daily, divided into 2 doses; Long-acting succinate is started at 25–100 mg once a day, up to 200 mg once a day.
• Nifedipine (long-acting, oral): Start at 30–60 mg once daily and increase at intervals of 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Methyldopa (oral): Start at 250 mg 2–3 times a day, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.

Note

• Avoid ACE inhibitors, angiotensin receptor blockers, and other RAAS-suppressing agents.
• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Metoprolol (oral): Not used in second-third degree AV block and sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia, cardiogenic shock and overt or decompensated heart failure; If the treatment is to be discontinued, the dose should be reduced over 1-2 weeks. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. Manage gestational hypertension with systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg without proteinuria or organ dysfunction on the same basis as preeclampsia; Re-evaluate the diagnosis of preeclampsia if proteinuria or organ dysfunction suggestive of preeclampsia develops.
2. Do not manage as an outpatient; hospitalize and rapidly assess maternal condition; Evaluate the fetus with fetal biometry, amniotic fluid and fetal well-being tests appropriate to the gestational age.
3. Measure BP with correct technique; If systolic BP is ≥160 mmHg and/or diastolic BP is ≥110 mmHg before and after birth, confirm by measuring again within 15 minutes; if persistent, initiate rapid-acting antihypertensive as soon as possible, no later than 30–60 minutes; If the BP threshold continues to be exceeded despite consecutive appropriate doses of the selected first-line agent, switch to another first-line agent and seek urgent consultation with a maternal-fetal medicine, anesthesiologist, or intensivist.
4. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
5. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture; Evaluate HELLP syndrome, acute fatty liver of pregnancy and thrombotic microangiopathy in the differential diagnosis in cases of thrombocytopenia, increased creatinine, elevated transaminases or hemolysis.
6. Perform delivery after stabilizing the mother; Determine the mode of delivery according to gestational age, cervix status, fetal presentation, fetal well-being and obstetric indications, regardless of the diagnosis of preeclampsia.
7. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
8. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; add BP control, weight management, smoking cessation, lipid profile, glucose metabolism, and renal function to the long-term follow-up plan; In cases of early-onset, severe, recurrent preeclampsia or complicated by fetal growth restriction, long-term cardiovascular monitoring should be especially stringent.
9. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• IV labetalol: 20 mg IV over 2 minutes; If BP is above threshold, 40 mg after 10 minutes, then 80 mg every 10 minutes (each dose over 2 minutes); maximum 300 mg total; alternatively, 1–2 mg/min IV infusion.
• Hydralazine: 5 mg IV or IM, followed by 5–10 mg IV every 20–40 minutes if necessary; maximum 20 mg total.
• Immediate-release oral nifedipine: 10–20 mg; Repeat after 20 minutes if necessary; then 10–20 mg every 2–6 hours if necessary; maximum 180 mg per day.
• If BP remains above threshold despite consecutive doses of one agent, switch to the other: IV labetalol after immediate-release nifedipine or hydralazine, IV hydralazine after IV labetalol; If there is no response, seek specialist support for second-line treatment.
• Oral antihypertensive therapy: initiate or continue for maintenance if BP is 140–159/90–109 mmHg or after acute severe hypertension is controlled; Titrate to target BP <140/90 mmHg.
• First option — Labetalol (oral): start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• First option — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Alternative — Methyldopa (oral): Start at 250 mg 2–3 times daily, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.
• Magnesium sulfate: in severe cases, initiate labor without waiting, together with the decision to deliver and stabilization (if cesarean section is to be performed before the labor begins, start before surgery, continue throughout surgery): 4 g IV loading dose in 5–15 minutes, then 1 g/hour IV maintenance; Continue infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Note that high or frequent doses of hydralazine increase the risk of maternal hypotension and fetal heart rate disturbances.
• Do not puncture or sublingual administration of immediate-release nifedipine capsule.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Avoid ACE inhibitors, angiotensin receptor blockers, and other RAAS-suppressing agents.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. Manage gestational hypertension with systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg without proteinuria or organ dysfunction on the same basis as preeclampsia; Re-evaluate the diagnosis of preeclampsia if proteinuria or organ dysfunction suggestive of preeclampsia develops.
2. Do not manage as an outpatient; Quickly evaluate the mother and fetus condition by hospitalizing them in a tertiary care center.
3. Measure BP with correct technique; If systolic BP is ≥160 mmHg and/or diastolic BP is ≥110 mmHg before and after birth, confirm by measuring again within 15 minutes; if persistent, initiate rapid-acting antihypertensive as soon as possible, no later than 30–60 minutes; If the BP threshold continues to be exceeded despite consecutive appropriate doses of the selected first-line agent, switch to another first-line agent and seek urgent consultation with a maternal-fetal medicine, anesthesiologist, or intensivist.
4. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
5. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture; Evaluate HELLP syndrome, acute fatty liver of pregnancy and thrombotic microangiopathy in the differential diagnosis in cases of thrombocytopenia, increased creatinine, elevated transaminases or hemolysis.
6. Evaluate the fetus with fetal biometry, amniotic fluid, and fetal well-being tests appropriate for gestational age; Plan NST or biophysical profile according to disease severity and gestational age; Pay attention to fetal growth restriction and oligohydramnios in early-onset disease. If growth restriction is suspected or biometry is abnormal, add umbilical artery Doppler.
7. Consider short-term expectant management only in carefully selected stable cases, under close monitoring in a tertiary center, for antenatal corticosteroid administration and fetal maturation.
8. Stabilize the mother and deliver regardless of gestational age in case of any deterioration in the mother or the fetus, especially if there is one of the following: severe BP uncontrolled despite the maximum dose, treatment-resistant headache, epigastric/right upper quadrant pain unresponsive to repeated analgesics, visual impairment, motor deficit or altered consciousness, stroke, myocardial infarction, HELLP, new or worsening renal dysfunction, pulmonary edema, eclampsia, suspicion of placental abruption; unreassuring fetal test, fetal death, persistent reverse diastolic flow in the umbilical artery.
9. Plan delivery at 34+0 weeks even if the mother and fetus remain stable during expectant management; do not use expectant management if the newborn is not expected to survive; do not delay indicated delivery to complete a course of corticosteroids.
10. Determine the mode of delivery according to gestational age, cervical status, fetal presentation, fetal well-being and obstetric indications, regardless of the diagnosis of preeclampsia.
11. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
12. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; add BP control, weight management, smoking cessation, lipid profile, glucose metabolism, and renal function to the long-term follow-up plan; In cases of early-onset, severe, recurrent preeclampsia or complicated by fetal growth restriction, long-term cardiovascular monitoring should be especially stringent.
13. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Single course if birth is expected within 7 days, pregnancy is at 23+0–33+6 weeks (from 22+0 weeks if active neonatal care is planned) and no previous cycle — Antenatal corticosteroid: betamethasone 12 mg IM, 2 doses 24 hours apart or dexamethasone 6 mg IM, 4 doses 12 hours apart.
• IV labetalol: 20 mg IV over 2 minutes; If BP is above threshold, 40 mg after 10 minutes, then 80 mg every 10 minutes (each dose over 2 minutes); maximum 300 mg total; alternatively, 1–2 mg/min IV infusion.
• Hydralazine: 5 mg IV or IM, followed by 5–10 mg IV every 20–40 minutes if necessary; maximum 20 mg total.
• Immediate-release oral nifedipine: 10–20 mg; Repeat after 20 minutes if necessary; then 10–20 mg every 2–6 hours if necessary; maximum 180 mg per day.
• If BP remains above threshold despite consecutive doses of one agent, switch to the other: IV labetalol after immediate-release nifedipine or hydralazine, IV hydralazine after IV labetalol; If there is no response, seek specialist support for second-line treatment.
• Oral antihypertensive therapy: initiate or continue for maintenance if BP is 140–159/90–109 mmHg or after acute severe hypertension is controlled; Titrate to target BP <140/90 mmHg.
• First option — Labetalol (oral): start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• First option — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Alternative — Methyldopa (oral): Start at 250 mg 2–3 times daily, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.
• Magnesium sulfate (seizure prophylaxis: start at initial evaluation, continue until completion of antenatal corticosteroid course (approximately 48 hours); discontinue if expectant management is to be continued, restart when labor is indicated) — 4 g IV loading dose over 5–15 minutes, followed by 1 g/hour IV maintenance; Continue infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Note that high or frequent doses of hydralazine increase the risk of maternal hypotension and fetal heart rate disturbances.
• Do not puncture or sublingual administration of immediate-release nifedipine capsule.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Avoid ACE inhibitors, angiotensin receptor blockers, and other RAAS-suppressing agents.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Avoid continuing antepartum magnesium prophylaxis for more than 48 hours.
• Below 32 weeks, magnesium sulfate also provides neonatal neuroprotection in preterm birth.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
2. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; Add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture.
3. Evaluate the fetus with fetal biometry, amniotic fluid, and fetal well-being tests appropriate for gestational age.
4. Measure BP with correct technique; If systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg before or after birth, confirm by measuring again within 15 minutes; if persistent, initiate emergency treatment with IV labetalol, IV hydralazine, or oral immediate-release nifedipine as soon as possible, no later than 30–60 minutes; Apply the 'Acute severe hypertension' selection in the algorithm for doses and repeat intervals.
5. Plan delivery at 37+0 weeks and later (labor induction is a suitable option); Determine the mode of delivery according to gestational age, cervix status, fetal presentation, fetal well-being and obstetric indications, regardless of the diagnosis of preeclampsia.
6. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
7. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; Include BP control, weight management, smoking cessation, lipid profile, glucose metabolism and kidney function in the long-term follow-up plan.
8. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Oral antihypertensive therapy: start when systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg.
• Labetalol (oral): Start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• Metoprolol (oral): start with immediate-release tartrate 50 mg twice daily, gradually increasing according to response; The usual dose during pregnancy is 100 mg twice a day; maximum 200 mg daily, divided into 2 doses; Long-acting succinate is started at 25–100 mg once a day, up to 200 mg once a day.
• Nifedipine (long-acting, oral): Start at 30–60 mg once daily and increase at intervals of 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Methyldopa (oral): Start at 250 mg 2–3 times a day, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.
• Magnesium sulfate: in the absence of severe features, base use on clinical risk and local practice; if severe features develop, start magnesium sulfate alongside stabilization and the decision to deliver, without waiting for labor (if cesarean birth is planned before labor, start before surgery and continue throughout): a 4 g IV loading dose over 5–15 minutes, followed by 1 g/hour IV maintenance; continue the infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Avoid ACE inhibitors, angiotensin receptor blockers, and other RAAS-suppressing agents.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding.
• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Metoprolol (oral): Not used in second-third degree AV block and sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia, cardiogenic shock and overt or decompensated heart failure; If the treatment is to be discontinued, the dose should be reduced over 1-2 weeks. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
2. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; Add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture.
3. Evaluate the fetus with fetal biometry, amniotic fluid, and fetal well-being tests appropriate for gestational age; Plan NST or biophysical profile according to disease severity and gestational age; If growth restriction is suspected or biometry is impaired, add umbilical artery Doppler.
4. Consider outpatient follow-up only in selected patients who are asymptomatic, have stable maternal and fetal conditions, comply with frequent check-ups, have access to hospital, and have reliable home BP measurement; If serious findings develop, discontinue outpatient monitoring and re-determine monitoring intensity, magnesium sulfate requirement, antihypertensive treatment and delivery time according to serious findings.
5. Measure BP with correct technique; If systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg before or after birth, confirm by measuring again within 15 minutes; if persistent, initiate emergency treatment with IV labetalol, IV hydralazine, or oral immediate-release nifedipine as soon as possible, no later than 30–60 minutes; Apply the 'Acute severe hypertension' selection in the algorithm for doses and repeat intervals.
6. Approach selectively at 34+0–36+6 weeks: if mother and fetus are stable, consider expectant management until 37+0 weeks with full counseling and close monitoring; planned preterm birth reduces adverse maternal outcomes but increases neonatal intensive care admission, individualize the decision; Reconsider the safety of expectant management in cases of unreassuring fetal testing, gross Doppler abnormality, significant growth restriction, or suspected placental abruption.
7. Determine the mode of delivery according to gestational age, cervical status, fetal presentation, fetal well-being and obstetric indications, regardless of the diagnosis of preeclampsia.
8. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
9. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; Include BP control, weight management, smoking cessation, lipid profile, glucose metabolism and kidney function in the long-term follow-up plan.
10. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Oral antihypertensive therapy: start when systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg.
• Labetalol (oral): Start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• Metoprolol (oral): start with immediate-release tartrate 50 mg twice daily, gradually increasing according to response; The usual dose during pregnancy is 100 mg twice a day; maximum 200 mg daily, divided into 2 doses; Long-acting succinate is started at 25–100 mg once a day, up to 200 mg once a day.
• Nifedipine (long-acting, oral): Start at 30–60 mg once daily and increase at intervals of 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Methyldopa (oral): Start at 250 mg 2–3 times a day, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.
• Magnesium sulfate: in the absence of severe features, base use on clinical risk and local practice; if severe features develop, start magnesium sulfate alongside stabilization and the decision to deliver, without waiting for labor (if cesarean birth is planned before labor, start before surgery and continue throughout): a 4 g IV loading dose over 5–15 minutes, followed by 1 g/hour IV maintenance; continue the infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Avoid ACE inhibitors, angiotensin receptor blockers, and other RAAS-suppressing agents.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding.
• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Metoprolol (oral): Not used in second-third degree AV block and sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia, cardiogenic shock and overt or decompensated heart failure; If the treatment is to be discontinued, the dose should be reduced over 1-2 weeks. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
2. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; Add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture.
3. Evaluate the fetus with fetal biometry, amniotic fluid, and fetal well-being tests appropriate for gestational age; Plan NST or biophysical profile according to disease severity and gestational age; Pay attention to fetal growth restriction and oligohydramnios in early-onset disease. If growth restriction is suspected or biometry is abnormal, add umbilical artery Doppler.
4. Consider outpatient follow-up only in selected patients who are asymptomatic, have stable maternal and fetal conditions, comply with frequent check-ups, have access to hospital, and have reliable home BP measurement; If serious findings develop, discontinue outpatient monitoring and re-determine monitoring intensity, magnesium sulfate requirement, antihypertensive treatment and delivery time according to serious findings.
5. Measure BP with correct technique; If systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg before or after birth, confirm by measuring again within 15 minutes; if persistent, initiate emergency treatment with IV labetalol, IV hydralazine, or oral immediate-release nifedipine as soon as possible, no later than 30–60 minutes; Apply the 'Acute severe hypertension' selection in the algorithm for doses and repeat intervals.
6. Individualize time of birth according to disease severity, maternal and fetal stability, and gestational age; If no serious findings develop, delivery is recommended at 37+0 weeks and later; the approach is selective at 34+0–36+6 weeks; Reconsider the safety of expectant management in cases of unreassuring fetal testing, gross Doppler abnormality, significant growth restriction, or suspected placental abruption.
7. Determine the mode of delivery according to gestational age, cervical status, fetal presentation, fetal well-being and obstetric indications, regardless of the diagnosis of preeclampsia.
8. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
9. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; Include BP control, weight management, smoking cessation, lipid profile, glucose metabolism and kidney function in the long-term follow-up plan.
10. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Oral antihypertensive therapy: start when systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg.
• Labetalol (oral): Start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• Metoprolol (oral): start with immediate-release tartrate 50 mg twice daily, gradually increasing according to response; The usual dose during pregnancy is 100 mg twice a day; maximum 200 mg daily, divided into 2 doses; Long-acting succinate is started at 25–100 mg once a day, up to 200 mg once a day.
• Nifedipine (long-acting, oral): Start at 30–60 mg once daily and increase at intervals of 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Methyldopa (oral): Start at 250 mg 2–3 times a day, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.
• Magnesium sulfate: unless serious findings, determine use based on clinical risk and facility practice; Seizure prophylaxis if serious findings develop: start with initial evaluation and continue until completion of antenatal corticosteroid course (approximately 48 hours); If expectant management is to be continued, discontinue, restart when indication for delivery occurs — 4 g IV loading dose over 5–15 minutes, followed by 1 g/hour IV maintenance; Continue infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Avoid ACE inhibitors, angiotensin receptor blockers, and other RAAS-suppressing agents.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding.
• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Avoid continuing antepartum magnesium prophylaxis for more than 48 hours.
• Below 32 weeks, magnesium sulfate also provides neonatal neuroprotection in preterm birth.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Metoprolol (oral): Not used in second-third degree AV block and sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia, cardiogenic shock and overt or decompensated heart failure; If the treatment is to be discontinued, the dose should be reduced over 1-2 weeks. Since metabolism decreases after birth, the need is re-evaluated.
• Metoprolol (oral): Its metabolism increases in mid and late pregnancy; If the clinical response is insufficient, the dose and dosing frequency are adjusted.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. Do not manage as an outpatient; hospitalize and rapidly assess maternal condition; Evaluate the fetus with fetal biometry, amniotic fluid and fetal well-being tests appropriate to the gestational age.
2. Measure BP with correct technique; If systolic BP is ≥160 mmHg and/or diastolic BP is ≥110 mmHg before and after birth, confirm by measuring again within 15 minutes; if persistent, initiate rapid-acting antihypertensive as soon as possible, no later than 30–60 minutes; If the BP threshold continues to be exceeded despite consecutive appropriate doses of the selected first-line agent, switch to another first-line agent and seek urgent consultation with a maternal-fetal medicine, anesthesiologist, or intensivist.
3. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
4. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture; Evaluate HELLP syndrome, acute fatty liver of pregnancy and thrombotic microangiopathy in the differential diagnosis in cases of thrombocytopenia, increased creatinine, elevated transaminases or hemolysis.
5. In known chronic kidney disease, do not apply the renal criterion solely using an absolute creatinine threshold; assess new deterioration from baseline together with other signs of preeclampsia.
6. Perform delivery after stabilizing the mother; Determine the mode of delivery according to gestational age, cervix status, fetal presentation, fetal well-being and obstetric indications, regardless of the diagnosis of preeclampsia.
7. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
8. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; add BP control, weight management, smoking cessation, lipid profile, glucose metabolism, and renal function to the long-term follow-up plan; In cases of early-onset, severe, recurrent preeclampsia or complicated by fetal growth restriction, long-term cardiovascular monitoring should be especially stringent.
9. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Rapid-acting antihypertensive (IV labetalol, IV hydralazine, or immediate-release oral nifedipine): administer only if systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg confirmed by repeat measurement within 15 minutes; choose one according to contraindications and clinical picture.
• IV labetalol: 20 mg IV over 2 minutes; If BP is above threshold, 40 mg after 10 minutes, then 80 mg every 10 minutes (each dose over 2 minutes); maximum 300 mg total; alternatively, 1–2 mg/min IV infusion.
• Hydralazine: 5 mg IV or IM, followed by 5–10 mg IV every 20–40 minutes if necessary; maximum 20 mg total.
• Immediate-release oral nifedipine: 10–20 mg; Repeat after 20 minutes if necessary; then 10–20 mg every 2–6 hours if necessary; maximum 180 mg per day.
• If BP remains above threshold despite consecutive doses of one agent, switch to the other: IV labetalol after immediate-release nifedipine or hydralazine, IV hydralazine after IV labetalol; If there is no response, seek specialist support for second-line treatment.
• Oral antihypertensive therapy: initiate or continue for maintenance if BP is 140–159/90–109 mmHg or after acute severe hypertension is controlled; Titrate to target BP <140/90 mmHg.
• First option — Labetalol (oral): start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• First option — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Alternative — Methyldopa (oral): Start at 250 mg 2–3 times daily, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.
• Magnesium sulfate: in severe cases, initiate labor without waiting, together with the decision to deliver and stabilization (if cesarean section is to be performed before the labor begins, start before surgery, continue throughout surgery): 4 g IV loading dose in 5–15 minutes, then 1 g/hour IV maintenance; Continue infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Note that high or frequent doses of hydralazine increase the risk of maternal hypotension and fetal heart rate disturbances.
• Do not puncture or sublingual administration of immediate-release nifedipine capsule.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Avoid ACE inhibitors, angiotensin receptor blockers, and other RAAS-suppressing agents.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Do not use labetalol (IV or oral) if the serious finding is pulmonary edema or acute heart failure; Apply 'Acute severe hypertension › Pulmonary edema or heart failure is present' in the algorithm for fluid restriction, oxygen, IV nitroglycerin and, if necessary, IV furosemide.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. Do not manage as an outpatient; Quickly evaluate the mother and fetus condition by hospitalizing them in a tertiary care center.
2. Measure BP with correct technique; If systolic BP is ≥160 mmHg and/or diastolic BP is ≥110 mmHg before and after birth, confirm by measuring again within 15 minutes; if persistent, initiate rapid-acting antihypertensive as soon as possible, no later than 30–60 minutes; If the BP threshold continues to be exceeded despite consecutive appropriate doses of the selected first-line agent, switch to another first-line agent and seek urgent consultation with a maternal-fetal medicine, anesthesiologist, or intensivist.
3. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
4. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture; Evaluate HELLP syndrome, acute fatty liver of pregnancy and thrombotic microangiopathy in the differential diagnosis in cases of thrombocytopenia, increased creatinine, elevated transaminases or hemolysis.
5. In known chronic kidney disease, do not apply the renal criterion solely using an absolute creatinine threshold; assess new deterioration from baseline together with other signs of preeclampsia.
6. Evaluate the fetus with fetal biometry, amniotic fluid, and fetal well-being tests appropriate for gestational age; Plan NST or biophysical profile according to disease severity and gestational age; Pay attention to fetal growth restriction and oligohydramnios in early-onset disease. If growth restriction is suspected or biometry is abnormal, add umbilical artery Doppler.
7. Consider short-term expectant management only in carefully selected stable cases, under close monitoring in a tertiary center, for antenatal corticosteroid administration and fetal maturation.
8. Stabilize the mother and deliver regardless of gestational age in case of any deterioration in the mother or the fetus, especially if there is one of the following: severe BP uncontrolled despite the maximum dose, treatment-resistant headache, epigastric/right upper quadrant pain unresponsive to repeated analgesics, visual impairment, motor deficit or altered consciousness, stroke, myocardial infarction, HELLP, new or worsening renal dysfunction, pulmonary edema, eclampsia, suspicion of placental abruption; unreassuring fetal test, fetal death, persistent reverse diastolic flow in the umbilical artery.
9. Plan delivery at 34+0 weeks even if the mother and fetus remain stable during expectant management; do not use expectant management if the newborn is not expected to survive; do not delay indicated delivery to complete a course of corticosteroids.
10. Determine the mode of delivery according to gestational age, cervical status, fetal presentation, fetal well-being and obstetric indications, regardless of the diagnosis of preeclampsia.
11. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
12. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; add BP control, weight management, smoking cessation, lipid profile, glucose metabolism, and renal function to the long-term follow-up plan; In cases of early-onset, severe, recurrent preeclampsia or complicated by fetal growth restriction, long-term cardiovascular monitoring should be especially stringent.
13. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Single course if birth is expected within 7 days, pregnancy is at 23+0–33+6 weeks (from 22+0 weeks if active neonatal care is planned) and no previous cycle — Antenatal corticosteroid: betamethasone 12 mg IM, 2 doses 24 hours apart or dexamethasone 6 mg IM, 4 doses 12 hours apart.
• Rapid-acting antihypertensive (IV labetalol, IV hydralazine, or immediate-release oral nifedipine): administer only if systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg confirmed by repeat measurement within 15 minutes; choose one according to contraindications and clinical picture.
• IV labetalol: 20 mg IV over 2 minutes; If BP is above threshold, 40 mg after 10 minutes, then 80 mg every 10 minutes (each dose over 2 minutes); maximum 300 mg total; alternatively, 1–2 mg/min IV infusion.
• Hydralazine: 5 mg IV or IM, followed by 5–10 mg IV every 20–40 minutes if necessary; maximum 20 mg total.
• Immediate-release oral nifedipine: 10–20 mg; Repeat after 20 minutes if necessary; then 10–20 mg every 2–6 hours if necessary; maximum 180 mg per day.
• If BP remains above threshold despite consecutive doses of one agent, switch to the other: IV labetalol after immediate-release nifedipine or hydralazine, IV hydralazine after IV labetalol; If there is no response, seek specialist support for second-line treatment.
• Oral antihypertensive therapy: initiate or continue for maintenance if BP is 140–159/90–109 mmHg or after acute severe hypertension is controlled; Titrate to target BP <140/90 mmHg.
• First option — Labetalol (oral): start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• First option — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Alternative — Methyldopa (oral): Start at 250 mg 2–3 times daily, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.
• Magnesium sulfate (seizure prophylaxis: start at initial evaluation, continue until completion of antenatal corticosteroid course (approximately 48 hours); discontinue if expectant management is to be continued, restart when labor is indicated) — 4 g IV loading dose over 5–15 minutes, followed by 1 g/hour IV maintenance; Continue infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Note that high or frequent doses of hydralazine increase the risk of maternal hypotension and fetal heart rate disturbances.
• Do not puncture or sublingual administration of immediate-release nifedipine capsule.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Avoid ACE inhibitors, angiotensin receptor blockers, and other RAAS-suppressing agents.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Do not use labetalol (IV or oral) if the serious finding is pulmonary edema or acute heart failure; Apply 'Acute severe hypertension › Pulmonary edema or heart failure is present' in the algorithm for fluid restriction, oxygen, IV nitroglycerin and, if necessary, IV furosemide.
• Avoid continuing antepartum magnesium prophylaxis for more than 48 hours.
• Below 32 weeks, magnesium sulfate also provides neonatal neuroprotection in preterm birth.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. New proteinuria, sudden increase in existing proteinuria, significant deterioration in BP control, or the occurrence of serious findings are suggestive of superimposed preeclampsia; Be careful to distinguish pregnancy physiology from the effects of chronic disease in diagnosis.
2. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
3. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; Add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture.
4. Evaluate the fetus with fetal biometry, amniotic fluid, and fetal well-being tests appropriate for gestational age.
5. Measure BP with correct technique; If systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg before or after birth, confirm by measuring again within 15 minutes; if persistent, initiate emergency treatment with IV labetalol, IV hydralazine, or oral immediate-release nifedipine as soon as possible, no later than 30–60 minutes; Apply the 'Acute severe hypertension' selection in the algorithm for doses and repeat intervals.
6. Plan delivery at 37+0 weeks and later (labor induction is a suitable option); Determine the mode of delivery according to gestational age, cervix status, fetal presentation, fetal well-being and obstetric indications, regardless of the diagnosis of preeclampsia.
7. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
8. Continue long-term monitoring of chronic hypertension; Monitor BP control, weight management, smoking cessation, lipid profile, glucose metabolism and kidney function.
9. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Oral antihypertensive therapy: continue current therapy compatible with pregnancy; If not receiving treatment, start at the 140/90 mmHg threshold and titrate to that threshold.
• First option — Labetalol (oral): start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• First option — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Alternative — Methyldopa (oral): Start at 250 mg 2–3 times daily, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.
• Magnesium sulfate: in the absence of severe features, base use on clinical risk and local practice; if severe features develop, start magnesium sulfate alongside stabilization and the decision to deliver, without waiting for labor (if cesarean birth is planned before labor, start before surgery and continue throughout): a 4 g IV loading dose over 5–15 minutes, followed by 1 g/hour IV maintenance; continue the infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Avoid ACE inhibitors, angiotensin receptor blockers and other RAAS-suppressing agents, and atenolol.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding.
• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. New proteinuria, sudden increase in existing proteinuria, significant deterioration in BP control, or the occurrence of serious findings are suggestive of superimposed preeclampsia; Be careful to distinguish pregnancy physiology from the effects of chronic disease in diagnosis.
2. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
3. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; Add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture.
4. Evaluate the fetus with fetal biometry, amniotic fluid, and fetal well-being tests appropriate for gestational age; Plan NST or biophysical profile according to disease severity and gestational age; If growth restriction is suspected or biometry is impaired, add umbilical artery Doppler.
5. Consider outpatient follow-up only in selected patients who are asymptomatic, have stable maternal and fetal conditions, comply with frequent check-ups, have access to hospital, and have reliable home BP measurement; If serious findings develop, discontinue outpatient monitoring and re-determine monitoring intensity, magnesium sulfate requirement, antihypertensive treatment and delivery time according to serious findings.
6. Measure BP with correct technique; If systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg before or after birth, confirm by measuring again within 15 minutes; if persistent, initiate emergency treatment with IV labetalol, IV hydralazine, or oral immediate-release nifedipine as soon as possible, no later than 30–60 minutes; Apply the 'Acute severe hypertension' selection in the algorithm for doses and repeat intervals.
7. Approach selectively at 34+0–36+6 weeks: if mother and fetus are stable, consider expectant management until 37+0 weeks with full counseling and close monitoring; planned preterm birth reduces adverse maternal outcomes but increases neonatal intensive care admission, individualize the decision; Reconsider the safety of expectant management in cases of unreassuring fetal testing, gross Doppler abnormality, significant growth restriction, or suspected placental abruption.
8. Determine the mode of delivery according to gestational age, cervical status, fetal presentation, fetal well-being and obstetric indications, regardless of the diagnosis of preeclampsia.
9. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
10. Continue long-term monitoring of chronic hypertension; Monitor BP control, weight management, smoking cessation, lipid profile, glucose metabolism and kidney function.
11. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Oral antihypertensive therapy: continue current therapy compatible with pregnancy; If not receiving treatment, start at the 140/90 mmHg threshold and titrate to that threshold.
• First option — Labetalol (oral): start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• First option — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Alternative — Methyldopa (oral): Start at 250 mg 2–3 times daily, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.
• Magnesium sulfate: in the absence of severe features, base use on clinical risk and local practice; if severe features develop, start magnesium sulfate alongside stabilization and the decision to deliver, without waiting for labor (if cesarean birth is planned before labor, start before surgery and continue throughout): a 4 g IV loading dose over 5–15 minutes, followed by 1 g/hour IV maintenance; continue the infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Avoid ACE inhibitors, angiotensin receptor blockers and other RAAS-suppressing agents, and atenolol.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding.
• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. New proteinuria, sudden increase in existing proteinuria, significant deterioration in BP control, or the occurrence of serious findings are suggestive of superimposed preeclampsia; Be careful to distinguish pregnancy physiology from the effects of chronic disease in diagnosis.
2. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
3. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; Add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture.
4. Evaluate the fetus with fetal biometry, amniotic fluid, and fetal well-being tests appropriate for gestational age; Plan NST or biophysical profile according to disease severity and gestational age; Pay attention to fetal growth restriction and oligohydramnios in early-onset disease. If growth restriction is suspected or biometry is abnormal, add umbilical artery Doppler.
5. Consider outpatient follow-up only in selected patients who are asymptomatic, have stable maternal and fetal conditions, comply with frequent check-ups, have access to hospital, and have reliable home BP measurement; If serious findings develop, discontinue outpatient monitoring and re-determine monitoring intensity, magnesium sulfate requirement, antihypertensive treatment and delivery time according to serious findings.
6. Measure BP with correct technique; If systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg before or after birth, confirm by measuring again within 15 minutes; if persistent, initiate emergency treatment with IV labetalol, IV hydralazine, or oral immediate-release nifedipine as soon as possible, no later than 30–60 minutes; Apply the 'Acute severe hypertension' selection in the algorithm for doses and repeat intervals.
7. Individualize time of birth according to disease severity, maternal and fetal stability, and gestational age; If no serious findings develop, delivery is recommended at 37+0 weeks and later; the approach is selective at 34+0–36+6 weeks; Reconsider the safety of expectant management in cases of unreassuring fetal testing, gross Doppler abnormality, significant growth restriction, or suspected placental abruption.
8. Determine the mode of delivery according to gestational age, cervical status, fetal presentation, fetal well-being and obstetric indications, regardless of the diagnosis of preeclampsia.
9. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
10. Continue long-term monitoring of chronic hypertension; Monitor BP control, weight management, smoking cessation, lipid profile, glucose metabolism and kidney function.
11. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Oral antihypertensive therapy: continue current therapy compatible with pregnancy; If not receiving treatment, start at the 140/90 mmHg threshold and titrate to that threshold.
• First option — Labetalol (oral): start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• First option — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Alternative — Methyldopa (oral): Start at 250 mg 2–3 times daily, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.
• Magnesium sulfate: unless serious findings, determine use based on clinical risk and facility practice; Seizure prophylaxis if serious findings develop: start with initial evaluation and continue until completion of antenatal corticosteroid course (approximately 48 hours); If expectant management is to be continued, discontinue, restart when indication for delivery occurs — 4 g IV loading dose over 5–15 minutes, followed by 1 g/hour IV maintenance; Continue infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Avoid ACE inhibitors, angiotensin receptor blockers and other RAAS-suppressing agents, and atenolol.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding.
• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Avoid continuing antepartum magnesium prophylaxis for more than 48 hours.
• Below 32 weeks, magnesium sulfate also provides neonatal neuroprotection in preterm birth.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. New proteinuria, sudden increase in existing proteinuria, significant deterioration in BP control, or the occurrence of serious findings are suggestive of superimposed preeclampsia; Be careful to distinguish pregnancy physiology from the effects of chronic disease in diagnosis.
2. Do not manage as an outpatient; hospitalize and rapidly assess maternal condition; Evaluate the fetus with fetal biometry, amniotic fluid and fetal well-being tests appropriate to the gestational age.
3. Measure BP with correct technique; If systolic BP is ≥160 mmHg and/or diastolic BP is ≥110 mmHg before and after birth, confirm by measuring again within 15 minutes; if persistent, initiate rapid-acting antihypertensive as soon as possible, no later than 30–60 minutes; If the BP threshold continues to be exceeded despite consecutive appropriate doses of the selected first-line agent, switch to another first-line agent and seek urgent consultation with a maternal-fetal medicine, anesthesiologist, or intensivist.
4. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
5. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture; Evaluate HELLP syndrome, acute fatty liver of pregnancy and thrombotic microangiopathy in the differential diagnosis in cases of thrombocytopenia, increased creatinine, elevated transaminases or hemolysis.
6. In known chronic kidney disease, do not apply the renal criterion solely using an absolute creatinine threshold; assess new deterioration from baseline together with other signs of preeclampsia.
7. Perform delivery after stabilizing the mother; Determine the mode of delivery according to gestational age, cervix status, fetal presentation, fetal well-being and obstetric indications, regardless of the diagnosis of preeclampsia.
8. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
9. Continue long-term monitoring of chronic hypertension; BP control, weight management, smoking cessation, monitor lipid profile, glucose metabolism and kidney function; In cases of early-onset, severe, recurrent preeclampsia or complicated by fetal growth restriction, long-term cardiovascular monitoring should be especially stringent.
10. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Oral antihypertensive therapy: continue current therapy compatible with pregnancy; If not receiving treatment, start at the 140/90 mmHg threshold and titrate to that threshold.
• First option — Labetalol (oral): start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• First option — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Alternative — Methyldopa (oral): Start at 250 mg 2–3 times daily, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.
• Rapid-acting antihypertensive (IV labetalol, IV hydralazine, or immediate-release oral nifedipine): administer only if systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg confirmed by repeat measurement within 15 minutes; choose one according to contraindications and clinical picture.
• IV labetalol: 20 mg IV over 2 minutes; If BP is above threshold, 40 mg after 10 minutes, then 80 mg every 10 minutes (each dose over 2 minutes); maximum 300 mg total; alternatively, 1–2 mg/min IV infusion.
• Hydralazine: 5 mg IV or IM, followed by 5–10 mg IV every 20–40 minutes if necessary; maximum 20 mg total.
• Immediate-release oral nifedipine: 10–20 mg; Repeat after 20 minutes if necessary; then 10–20 mg every 2–6 hours if necessary; maximum 180 mg per day.
• If BP remains above threshold despite consecutive doses of one agent, switch to the other: IV labetalol after immediate-release nifedipine or hydralazine, IV hydralazine after IV labetalol; If there is no response, seek specialist support for second-line treatment.
• Magnesium sulfate: in severe cases, initiate labor without waiting, together with the decision to deliver and stabilization (if cesarean section is to be performed before the labor begins, start before surgery, continue throughout surgery): 4 g IV loading dose in 5–15 minutes, then 1 g/hour IV maintenance; Continue infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Note that high or frequent doses of hydralazine increase the risk of maternal hypotension and fetal heart rate disturbances.
• Do not puncture or sublingual administration of immediate-release nifedipine capsule.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Avoid ACE inhibitors, angiotensin receptor blockers and other RAAS-suppressing agents, and atenolol.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Do not use labetalol (IV or oral) if the serious finding is pulmonary edema or acute heart failure; Apply 'Acute severe hypertension › Pulmonary edema or heart failure is present' in the algorithm for fluid restriction, oxygen, IV nitroglycerin and, if necessary, IV furosemide.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. New proteinuria, sudden increase in existing proteinuria, significant deterioration in BP control, or the occurrence of serious findings are suggestive of superimposed preeclampsia; Be careful to distinguish pregnancy physiology from the effects of chronic disease in diagnosis.
2. Do not manage as an outpatient; Quickly evaluate the mother and fetus condition by hospitalizing them in a tertiary care center.
3. Measure BP with correct technique; If systolic BP is ≥160 mmHg and/or diastolic BP is ≥110 mmHg before and after birth, confirm by measuring again within 15 minutes; if persistent, initiate rapid-acting antihypertensive as soon as possible, no later than 30–60 minutes; If the BP threshold continues to be exceeded despite consecutive appropriate doses of the selected first-line agent, switch to another first-line agent and seek urgent consultation with a maternal-fetal medicine, anesthesiologist, or intensivist.
4. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
5. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture; Evaluate HELLP syndrome, acute fatty liver of pregnancy and thrombotic microangiopathy in the differential diagnosis in cases of thrombocytopenia, increased creatinine, elevated transaminases or hemolysis.
6. In known chronic kidney disease, do not apply the renal criterion solely using an absolute creatinine threshold; assess new deterioration from baseline together with other signs of preeclampsia.
7. Evaluate the fetus with fetal biometry, amniotic fluid, and fetal well-being tests appropriate for gestational age; Plan NST or biophysical profile according to disease severity and gestational age; Pay attention to fetal growth restriction and oligohydramnios in early-onset disease. If growth restriction is suspected or biometry is abnormal, add umbilical artery Doppler.
8. Consider short-term expectant management only in carefully selected stable cases, under close monitoring in a tertiary center, for antenatal corticosteroid administration and fetal maturation.
9. Stabilize the mother and deliver regardless of gestational age in case of any deterioration in the mother or the fetus, especially if there is one of the following: severe BP uncontrolled despite the maximum dose, treatment-resistant headache, epigastric/right upper quadrant pain unresponsive to repeated analgesics, visual impairment, motor deficit or altered consciousness, stroke, myocardial infarction, HELLP, new or worsening renal dysfunction, pulmonary edema, eclampsia, suspicion of placental abruption; unreassuring fetal test, fetal death, persistent reverse diastolic flow in the umbilical artery.
10. Plan delivery at 34+0 weeks even if the mother and fetus remain stable during expectant management; do not use expectant management if the newborn is not expected to survive; do not delay indicated delivery to complete a course of corticosteroids.
11. Determine the mode of delivery according to gestational age, cervical status, fetal presentation, fetal well-being and obstetric indications, regardless of the diagnosis of preeclampsia.
12. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
13. Continue long-term monitoring of chronic hypertension; BP control, weight management, smoking cessation, monitor lipid profile, glucose metabolism and kidney function; In cases of early-onset, severe, recurrent preeclampsia or complicated by fetal growth restriction, long-term cardiovascular monitoring should be especially stringent.
14. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Single course if birth is expected within 7 days, pregnancy is at 23+0–33+6 weeks (from 22+0 weeks if active neonatal care is planned) and no previous cycle — Antenatal corticosteroid: betamethasone 12 mg IM, 2 doses 24 hours apart or dexamethasone 6 mg IM, 4 doses 12 hours apart.
• Oral antihypertensive therapy: continue current therapy compatible with pregnancy; If not receiving treatment, start at the 140/90 mmHg threshold and titrate to that threshold.
• First option — Labetalol (oral): start at 100 mg twice daily, increase by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• First option — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• Alternative — Methyldopa (oral): Start at 250 mg 2–3 times daily, increasing every 2 days at the earliest; up to 3000 mg daily in divided doses.
• Rapid-acting antihypertensive (IV labetalol, IV hydralazine, or immediate-release oral nifedipine): administer only if systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg confirmed by repeat measurement within 15 minutes; choose one according to contraindications and clinical picture.
• IV labetalol: 20 mg IV over 2 minutes; If BP is above threshold, 40 mg after 10 minutes, then 80 mg every 10 minutes (each dose over 2 minutes); maximum 300 mg total; alternatively, 1–2 mg/min IV infusion.
• Hydralazine: 5 mg IV or IM, followed by 5–10 mg IV every 20–40 minutes if necessary; maximum 20 mg total.
• Immediate-release oral nifedipine: 10–20 mg; Repeat after 20 minutes if necessary; then 10–20 mg every 2–6 hours if necessary; maximum 180 mg per day.
• If BP remains above threshold despite consecutive doses of one agent, switch to the other: IV labetalol after immediate-release nifedipine or hydralazine, IV hydralazine after IV labetalol; If there is no response, seek specialist support for second-line treatment.
• Magnesium sulfate (seizure prophylaxis: start at initial evaluation, continue until completion of antenatal corticosteroid course (approximately 48 hours); discontinue if expectant management is to be continued, restart when labor is indicated) — 4 g IV loading dose over 5–15 minutes, followed by 1 g/hour IV maintenance; Continue infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Note that high or frequent doses of hydralazine increase the risk of maternal hypotension and fetal heart rate disturbances.
• Do not puncture or sublingual administration of immediate-release nifedipine capsule.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Avoid ACE inhibitors, angiotensin receptor blockers and other RAAS-suppressing agents, and atenolol.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Do not use labetalol (IV or oral) if the serious finding is pulmonary edema or acute heart failure; Apply 'Acute severe hypertension › Pulmonary edema or heart failure is present' in the algorithm for fluid restriction, oxygen, IV nitroglycerin and, if necessary, IV furosemide.
• Avoid continuing antepartum magnesium prophylaxis for more than 48 hours.
• Below 32 weeks, magnesium sulfate also provides neonatal neuroprotection in preterm birth.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Methyldopa (oral): It can be stopped within 2 days after birth and switched to another medication.

Approach

1. Verify systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg by remeasurement within 15 minutes using correct technique; if persistent, initiate rapid-acting treatment as soon as possible, no later than 30–60 minutes; If the BP threshold continues to be exceeded despite consecutive appropriate doses of the selected first-line agent, switch to another first-line agent and seek urgent consultation with a maternal-fetal medicine, anesthesiologist, or intensivist.
2. Do not manage as an outpatient; Quickly evaluate the maternal condition in the hospital and evaluate fetal well-being with tests appropriate to the gestational age.
3. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
4. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; Add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture.
5. Determine the underlying condition: if severe hypertension develops in gestational hypertension, adjust management on the same basis as for preeclampsia; Suspect preeclampsia superimposed on chronic hypertension.
6. Expectant management may not be safe in resistant severe hypertension; Re-evaluate the time of birth according to maternal and fetal status.

Treatment

• IV labetalol: 20 mg IV over 2 minutes; If BP is above threshold, 40 mg after 10 minutes, then 80 mg every 10 minutes (each dose over 2 minutes); maximum 300 mg total; alternatively, 1–2 mg/min IV infusion.
• Hydralazine: 5 mg IV or IM, followed by 5–10 mg IV every 20–40 minutes if necessary; maximum 20 mg total.
• Immediate-release oral nifedipine: 10–20 mg; Repeat after 20 minutes if necessary; then 10–20 mg every 2–6 hours if necessary; maximum 180 mg per day.
• If BP remains above threshold despite consecutive doses of one agent, switch to the other: IV labetalol after immediate-release nifedipine or hydralazine, IV hydralazine after IV labetalol; If there is no response, seek specialist support for second-line treatment.
• Nicardipine: start at 5 mg/hour IV via infusion pump; increase by 2.5 mg/hour every 5–15 minutes based on target BP; maximum 15 mg/hour. Stop infusion in unacceptable hypotension or tachycardia; When BP and pulse rate improve, restart at a lower rate of 3–5 mg/hour.
• Magnesium sulfate in gestational hypertension with severe preeclampsia or severe hypertension: initiate labor without waiting, with the decision to deliver and stabilization (if cesarean section is to be performed before labor begins, start before surgery, continue throughout surgery): 4 g IV loading dose in 5–15 minutes, followed by 1 g/hour IV maintenance; Continue infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Note that high or frequent doses of hydralazine increase the risk of maternal hypotension and fetal heart rate disturbances.
• Do not puncture or sublingual administration of immediate-release nifedipine capsule.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Avoid ACE inhibitors, angiotensin receptor blockers, and other RAAS-suppressing agents.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Nicardipine: do not use in severe aortic stenosis; closely monitor BP and pulse response in angina, heart failure, hepatic dysfunction or renal dysfunction.

Approach

1. Verify systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg by remeasurement within 15 minutes using correct technique; if persistent, initiate rapid-acting treatment as soon as possible, no later than 30–60 minutes; If the BP threshold continues to be exceeded despite consecutive appropriate doses of the selected first-line agent, switch to another first-line agent and seek urgent consultation with a maternal-fetal medicine, anesthesiologist, or intensivist.
2. Do not delay emergency BP treatment with oral immediate-release nifedipine while waiting for IV access; establish IV access at the same time for magnesium sulfate and any IV treatments that may be needed.
3. Do not manage as an outpatient; Quickly evaluate the maternal condition in the hospital and evaluate fetal well-being with tests appropriate to the gestational age.
4. Systematically inquire about sudden increase in headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, altered consciousness, oliguria, and edema; Plan ECG and ECHO in cases of shortness of breath, chest pain, orthopnea, significant palpitations, decrease in oxygen saturation or signs of pulmonary edema. Do not accept shortness of breath as physiological in preeclampsia.
5. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; Add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture.
6. Determine the underlying condition: if severe hypertension develops in gestational hypertension, adjust management on the same basis as for preeclampsia; Suspect preeclampsia superimposed on chronic hypertension.
7. Expectant management may not be safe in resistant severe hypertension; Re-evaluate the time of birth according to maternal and fetal status.

Treatment

• Immediate-release oral nifedipine: 10–20 mg; Repeat after 20 minutes if necessary; then 10–20 mg every 2–6 hours if necessary; maximum 180 mg per day.
• If BP remains above threshold despite consecutive doses of one agent, switch to the other: IV labetalol after immediate-release nifedipine or hydralazine, IV hydralazine after IV labetalol; If there is no response, seek specialist support for second-line treatment.
• IV labetalol: 20 mg IV over 2 minutes; If BP is above threshold, 40 mg after 10 minutes, then 80 mg every 10 minutes (each dose over 2 minutes); maximum 300 mg total; alternatively, 1–2 mg/min IV infusion.
• Hydralazine: 5 mg IV or IM, followed by 5–10 mg IV every 20–40 minutes if necessary; maximum 20 mg total.
• Magnesium sulfate in gestational hypertension with severe preeclampsia or severe hypertension: initiate labor without waiting, with the decision to deliver and stabilization (if cesarean section is to be performed before labor begins, start before surgery, continue throughout surgery): 4 g IV loading dose in 5–15 minutes, followed by 1 g/hour IV maintenance; Continue infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Do not puncture or sublingual administration of immediate-release nifedipine capsule.
• Note that high or frequent doses of hydralazine increase the risk of maternal hypotension and fetal heart rate disturbances.
• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Avoid ACE inhibitors, angiotensin receptor blockers, and other RAAS-suppressing agents.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.

Approach

1. Verify systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg by remeasurement within 15 minutes using correct technique; if persistent, initiate rapid-acting treatment as soon as possible, no later than 30–60 minutes; If BP remains above threshold or clinical deterioration occurs, seek urgent consultation with maternal-fetal medicine, anesthesiologist and intensivist.
2. Do not manage as an outpatient; Multidisciplinary management with cardiology, maternal-fetal medicine, anesthesia and intensive care in a tertiary care center; Closely monitor oxygen saturation, lung examination, urine output, and fluid balance.
3. Perform ECG and ECHO; assess left and right ventricular function, diastolic function, and pulmonary pressures; Request BNP/NT-proBNP and interpret it together with the clinical picture, examination, ECHO and laboratory (it does not make a diagnosis alone).
4. Perform baseline laboratory evaluation for preeclampsia; If it is accompanied by preeclampsia, consider pulmonary edema as a serious finding.
5. Evaluate fetal well-being with tests appropriate to the gestational age; Perform delivery regardless of gestational age after stabilizing the mother in pulmonary edema due to preeclampsia; In pulmonary edema caused by another cause, determine the time of birth in a multidisciplinary manner based on the mother-fetus status and cardiac findings.

Treatment

• Implement fluid restriction.
• Oxygen: If SpO2 is less than 90% or PaO2 is less than 60 mmHg, oxygen is given; SpO2 is maintained at least 90%, preferably 95% or above; If SpO2 remains below 95% despite oxygen or respiratory distress (respiratory rate >25/min) persists, noninvasive positive pressure ventilation is applied; Intubation and invasive ventilation are applied in progressive respiratory failure despite oxygen or noninvasive support.
• If necessary — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in patients who have not previously used diuretics; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• Nitroglycerin: Start with 5 µg/min IV infusion, increase every 3–5 minutes to a maximum of 100 µg/min; It is given together with a diuretic.
• Hydralazine: 5 mg IV or IM, followed by 5–10 mg IV every 20–40 minutes if necessary; maximum 20 mg total.
• Immediate-release oral nifedipine: 10–20 mg; Repeat after 20 minutes if necessary; then 10–20 mg every 2–6 hours if necessary; maximum 180 mg per day.
• Nicardipine: start at 5 mg/hour IV via infusion pump; increase by 2.5 mg/hour every 5–15 minutes based on target BP; maximum 15 mg/hour. Stop infusion in unacceptable hypotension or tachycardia; When BP and pulse rate improve, restart at a lower rate of 3–5 mg/hour.
• If preeclampsia is also present, start magnesium sulfate alongside stabilization and the decision to deliver, without waiting for labor (if cesarean birth is planned before labor, start before surgery and continue throughout): a 4 g IV loading dose over 5–15 minutes, followed by 1 g/hour IV maintenance; continue the infusion for 24 hours after birth.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Do not use labetalol in pulmonary edema.
• Note that high or frequent doses of hydralazine increase the risk of maternal hypotension and fetal heart rate disturbances.
• Do not puncture or sublingual administration of immediate-release nifedipine capsule.
• Avoid ACE inhibitors, angiotensin receptor blockers, and other RAAS-suppressing agents.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Nicardipine: do not use in severe aortic stenosis; closely monitor BP and pulse response in angina, heart failure, hepatic dysfunction or renal dysfunction.
• Furosemide (IV): Since excessive diuresis during pregnancy may reduce uterine blood flow and placental perfusion, it is used with caution and the dose is titrated only in cases of pulmonary congestion or volume overload.
• Nitroglycerin: Start if systolic BP is above 110 mmHg.

Approach

1. Confirm postpartum systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg by remeasurement within 15 minutes; if persistent, initiate rapid-acting treatment as soon as possible, no later than 30–60 minutes; If the BP threshold continues to be exceeded despite consecutive appropriate doses of the selected first-line agent, switch to another first-line agent and seek urgent consultation with a maternal-fetal medicine, anesthesiologist, or intensivist.
2. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, monitor BP closely during the first week and describe in detail warning symptoms such as headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema before discharge.
3. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; Add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture.
4. Consider cardiology evaluation and ECHO if postpartum hypertension persists or evidence of shortness of breath, chest pain, orthopnea, or pulmonary edema occurs.
5. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; Include BP control, weight management, smoking cessation, lipid profile, glucose metabolism and kidney function in the long-term follow-up plan.
6. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• IV labetalol: 20 mg IV over 2 minutes; If BP is above threshold, 40 mg after 10 minutes, then 80 mg every 10 minutes (each dose over 2 minutes); maximum 300 mg total; alternatively, 1–2 mg/min IV infusion.
• Hydralazine: 5 mg IV or IM, followed by 5–10 mg IV every 20–40 minutes if necessary; maximum 20 mg total.
• Immediate-release oral nifedipine: 10–20 mg; Repeat after 20 minutes if necessary; then 10–20 mg every 2–6 hours if necessary; maximum 180 mg per day.
• If BP remains above threshold despite consecutive doses of one agent, switch to the other: IV labetalol after immediate-release nifedipine or hydralazine, IV hydralazine after IV labetalol; If there is no response, seek specialist support for second-line treatment.
• Magnesium sulfate in gestational hypertension with severe preeclampsia or severe hypertension: continue the infusion started before birth at 1 g/hour IV without reloading for 24 hours after birth; If not given before birth, give a loading dose of 4 g IV over 5–15 minutes, followed by 1 g/hour IV for 24 hours.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.
• In uncomplicated postpartum hypertension — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• In uncomplicated postpartum hypertension — Labetalol (oral): Start at 100 mg twice daily, increasing by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• If labetalol is not available in uncomplicated postpartum hypertension — Metoprolol (oral): start with immediate-release tartrate 50 mg twice daily, gradually increasing according to response; The usual dose during pregnancy is 100 mg twice a day; maximum 200 mg daily, divided into 2 doses; Long-acting succinate is started at 25–100 mg once a day, up to 200 mg once a day.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Note that high or frequent doses of hydralazine increase the risk of maternal hypotension.
• Do not puncture or sublingual administration of immediate-release nifedipine capsule.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding; nifedipine, labetalol and metoprolol are compatible with breastfeeding.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Individualize the threshold for starting oral therapy and the BP target in non-severe postpartum hypertension based on repeated measurements and the clinical picture.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Metoprolol (oral): Not used in second-third degree AV block and sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia, cardiogenic shock and overt or decompensated heart failure; If the treatment is to be discontinued, the dose should be reduced over 1-2 weeks. Since metabolism decreases after birth, the need is re-evaluated.

Approach

1. Confirm postpartum systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg by remeasurement within 15 minutes; if persistent, initiate rapid-acting treatment as soon as possible, no later than 30–60 minutes; If BP remains above threshold or clinical deterioration occurs, seek urgent consultation with maternal-fetal medicine, anesthesiologist and intensivist.
2. Multidisciplinary management with cardiology, maternal-fetal medicine, anesthesia and intensive care in a tertiary care center; Closely monitor oxygen saturation, lung examination, urine output, and fluid balance.
3. Perform cardiology evaluation and ECHO; In case of suspicion of heart failure or pulmonary edema, interpret BNP/NT-proBNP together with the clinical picture, examination and ECHO.
4. Perform baseline laboratory evaluation for preeclampsia; If it is accompanied by preeclampsia, consider pulmonary edema as a serious finding.
5. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Describe in detail any warning symptoms before discharge, such as headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
6. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; Include BP control, weight management, smoking cessation, lipid profile, glucose metabolism and kidney function in the long-term follow-up plan.
7. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Implement fluid restriction.
• Oxygen: If SpO2 is less than 90% or PaO2 is less than 60 mmHg, oxygen is given; SpO2 is maintained at least 90%, preferably 95% or above; If SpO2 remains below 95% despite oxygen or respiratory distress (respiratory rate >25/min) persists, noninvasive positive pressure ventilation is applied; Intubation and invasive ventilation are applied in progressive respiratory failure despite oxygen or noninvasive support.
• If necessary — Furosemide (IV): 40 mg IV, slow bolus over 1–2 minutes in patients who have not previously used diuretics; For those using oral loop diuretics, twice the daily oral dose of furosemide (or equivalent loop diuretic) IV; 2–3 boluses or continuous infusion per day; continuous infusion and high doses (≥160 mg) given at a rate of up to 4 mg/min; maximum 600 mg per day (up to 1000 mg may be considered in severe renal impairment).
• Nitroglycerin: Start with 5 µg/min IV infusion, increase every 3–5 minutes to a maximum of 100 µg/min; It is given together with a diuretic.
• Hydralazine: 5 mg IV or IM, followed by 5–10 mg IV every 20–40 minutes if necessary; maximum 20 mg total.
• Immediate-release oral nifedipine: 10–20 mg; Repeat after 20 minutes if necessary; then 10–20 mg every 2–6 hours if necessary; maximum 180 mg per day.
• Magnesium sulfate if accompanied by preeclampsia: continue the infusion started before birth at 1 g/hour IV without reloading for 24 hours after birth; If not given before birth, give a loading dose of 4 g IV over 5–15 minutes, followed by 1 g/hour IV for 24 hours.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.

Note

• Do not use labetalol in pulmonary edema.
• Note that high or frequent doses of hydralazine increase the risk of maternal hypotension.
• Do not puncture or sublingual administration of immediate-release nifedipine capsule.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Nitroglycerin: Start if systolic BP is above 110 mmHg.

Approach

1. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
2. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture; Evaluate HELLP syndrome, acute fatty liver of pregnancy and thrombotic microangiopathy in the differential diagnosis in cases of thrombocytopenia, increased creatinine, elevated transaminases or hemolysis.
3. Consider cardiology evaluation and ECHO if postpartum hypertension persists or evidence of shortness of breath, chest pain, orthopnea, or pulmonary edema occurs.
4. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; add BP control, weight management, smoking cessation, lipid profile, glucose metabolism, and renal function to the long-term follow-up plan; In cases of early-onset, severe, recurrent preeclampsia or complicated by fetal growth restriction, long-term cardiovascular monitoring should be especially stringent.
5. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Magnesium sulfate: continue infusion started before birth at 1 g/hour IV for 24 hours after birth without reloading; If not given before birth, give a loading dose of 4 g IV over 5–15 minutes, followed by 1 g/hour IV for 24 hours.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.
• In severe postpartum hypertension (≥160/110 mmHg), begin without delay: immediate-release oral nifedipine 10–20 mg, IV labetalol 20 mg (over 2 minutes), or IV/IM hydralazine 5 mg; For repeat intervals and upper dose limits, apply 'Acute severe hypertension › Postpartum' in the algorithm.
• In uncomplicated postpartum hypertension — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• In uncomplicated postpartum hypertension — Labetalol (oral): Start at 100 mg twice daily, increasing by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• If labetalol is not available in uncomplicated postpartum hypertension — Metoprolol (oral): start with immediate-release tartrate 50 mg twice daily, gradually increasing according to response; The usual dose during pregnancy is 100 mg twice a day; maximum 200 mg daily, divided into 2 doses; Long-acting succinate is started at 25–100 mg once a day, up to 200 mg once a day.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding; nifedipine, labetalol and metoprolol are compatible with breastfeeding.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Individualize the threshold for starting oral therapy and the BP target in non-severe postpartum hypertension based on repeated measurements and the clinical picture.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Metoprolol (oral): Not used in second-third degree AV block and sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia, cardiogenic shock and overt or decompensated heart failure; If the treatment is to be discontinued, the dose should be reduced over 1-2 weeks. Since metabolism decreases after birth, the need is re-evaluated.

Approach

1. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
2. Request complete blood count and platelets, serum creatinine, AST/ALT, bilirubin, and quantitative urine protein; Add LDH, peripheral smear, coagulation tests and uric acid according to the clinical picture.
3. Consider cardiology evaluation and ECHO if postpartum hypertension persists or evidence of shortness of breath, chest pain, orthopnea, or pulmonary edema occurs.
4. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; Include BP control, weight management, smoking cessation, lipid profile, glucose metabolism and kidney function in the long-term follow-up plan.
5. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Magnesium sulfate: unless serious findings, determine postpartum use based on clinical risk and facility practice; If serious findings develop, administer 4 g IV load (in 5–15 minutes), followed by 1 g/hour IV for 24 hours.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.
• In severe postpartum hypertension (≥160/110 mmHg), begin without delay: immediate-release oral nifedipine 10–20 mg, IV labetalol 20 mg (over 2 minutes), or IV/IM hydralazine 5 mg; For repeat intervals and upper dose limits, apply 'Acute severe hypertension › Postpartum' in the algorithm.
• In uncomplicated postpartum hypertension — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• In uncomplicated postpartum hypertension — Labetalol (oral): Start at 100 mg twice daily, increasing by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• If labetalol is not available in uncomplicated postpartum hypertension — Metoprolol (oral): start with immediate-release tartrate 50 mg twice daily, gradually increasing according to response; The usual dose during pregnancy is 100 mg twice a day; maximum 200 mg daily, divided into 2 doses; Long-acting succinate is started at 25–100 mg once a day, up to 200 mg once a day.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Avoid iatrogenic fluid overload; Monitor fluid balance as closely as antihypertensive therapy.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding; nifedipine, labetalol and metoprolol are compatible with breastfeeding.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Individualize the threshold for starting oral therapy and the BP target in non-severe postpartum hypertension based on repeated measurements and the clinical picture.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Metoprolol (oral): Not used in second-third degree AV block and sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia, cardiogenic shock and overt or decompensated heart failure; If the treatment is to be discontinued, the dose should be reduced over 1-2 weeks. Since metabolism decreases after birth, the need is re-evaluated.

Approach

1. Closely monitor BP in the first week postpartum (may rise again in the first days, there is a risk of serious hypertension); If hypertension persists or evidence of shortness of breath, chest pain, orthopnea, or pulmonary edema occurs, consider cardiology evaluation and ECHO.
2. Preeclampsia may develop after birth; Monitor for new proteinuria, organ dysfunction, and warning signs.
3. In gestational hypertension, if hypertension persists for more than 12 weeks, re-evaluate for chronic hypertension; Plan long-term follow-up including BP control, weight management, glucose and lipid assessment, kidney function and lifestyle counseling.
4. Assess the risk of postpartum VTE (hypertension and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• In severe postpartum hypertension (≥160/110 mmHg), begin without delay: immediate-release oral nifedipine 10–20 mg, IV labetalol 20 mg (over 2 minutes), or IV/IM hydralazine 5 mg; For repeat intervals and upper dose limits, apply 'Acute severe hypertension › Postpartum' in the algorithm.
• In uncomplicated postpartum hypertension — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• In uncomplicated postpartum hypertension — Labetalol (oral): Start at 100 mg twice daily, increasing by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• If labetalol is not available in uncomplicated postpartum hypertension — Metoprolol (oral): start with immediate-release tartrate 50 mg twice daily, gradually increasing according to response; The usual dose during pregnancy is 100 mg twice a day; maximum 200 mg daily, divided into 2 doses; Long-acting succinate is started at 25–100 mg once a day, up to 200 mg once a day.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding; nifedipine, labetalol and metoprolol are compatible with breastfeeding.
• Individualize the threshold for starting oral therapy and the BP target in non-severe postpartum hypertension based on repeated measurements and the clinical picture.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Metoprolol (oral): Not used in second-third degree AV block and sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia, cardiogenic shock and overt or decompensated heart failure; If the treatment is to be discontinued, the dose should be reduced over 1-2 weeks. Since metabolism decreases after birth, the need is re-evaluated.

Approach

1. Confirm new hypertension; inquire about symptoms and evaluate with complete blood count, platelets, creatinine, AST/ALT, bilirubin and quantitative urine protein; Note that preeclampsia can also develop with organ dysfunction without proteinuria.
2. If there are serious findings, evaluate and monitor in hospital.
3. If systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg, confirm by measuring again in 15 minutes; if persistent, initiate rapid-acting antihypertensive as soon as possible, no later than 30–60 minutes; If the BP threshold continues to be exceeded despite consecutive appropriate doses of the selected first-line agent, switch to another first-line agent and seek urgent consultation with a maternal-fetal medicine, anesthesiologist, or intensivist.
4. Closely monitor BP, neurological signs, kidney and liver functions, and platelet count in the first 24–72 hours after birth (eclampsia may also develop after birth); Since BP may rise again, especially in the first week, describe warning symptoms in detail before discharge, such as headache, visual impairment, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
5. Consider cardiology evaluation and ECHO if postpartum hypertension persists or evidence of shortness of breath, chest pain, orthopnea, or pulmonary edema occurs.
6. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; Include BP control, weight management, smoking cessation, lipid profile, glucose metabolism and kidney function in the long-term follow-up plan.
7. Assess the risk of postpartum VTE (preeclampsia/eclampsia, hypertension, and cesarean section are risk factors); Individualize thromboprophylaxis according to risk stratification.

Treatment

• Rapid-acting antihypertensive (IV labetalol, IV hydralazine, or immediate-release oral nifedipine): administer only if systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg confirmed by repeat measurement within 15 minutes; choose one according to contraindications and clinical picture.
• IV labetalol: 20 mg IV over 2 minutes; If BP is above threshold, 40 mg after 10 minutes, then 80 mg every 10 minutes (each dose over 2 minutes); maximum 300 mg total; alternatively, 1–2 mg/min IV infusion.
• Hydralazine: 5 mg IV or IM, followed by 5–10 mg IV every 20–40 minutes if necessary; maximum 20 mg total.
• Immediate-release oral nifedipine: 10–20 mg; Repeat after 20 minutes if necessary; then 10–20 mg every 2–6 hours if necessary; maximum 180 mg per day.
• If BP remains above threshold despite consecutive doses of one agent, switch to the other: IV labetalol after immediate-release nifedipine or hydralazine, IV hydralazine after IV labetalol; If there is no response, seek specialist support for second-line treatment.
• Magnesium sulfate in severe preeclampsia: Give a 4 g IV loading dose over 5–15 minutes, followed by a 1 g/hour IV maintenance infusion for 24 hours.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.
• In uncomplicated postpartum hypertension — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• In uncomplicated postpartum hypertension — Labetalol (oral): Start at 100 mg twice daily, increasing by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• If labetalol is not available in uncomplicated postpartum hypertension — Metoprolol (oral): start with immediate-release tartrate 50 mg twice daily, gradually increasing according to response; The usual dose during pregnancy is 100 mg twice a day; maximum 200 mg daily, divided into 2 doses; Long-acting succinate is started at 25–100 mg once a day, up to 200 mg once a day.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Note that high or frequent doses of hydralazine increase the risk of maternal hypotension.
• Do not puncture or sublingual administration of immediate-release nifedipine capsule.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding; nifedipine, labetalol and metoprolol are compatible with breastfeeding.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Individualize the threshold for starting oral therapy and the BP target in non-severe postpartum hypertension based on repeated measurements and the clinical picture.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Metoprolol (oral): Not used in second-third degree AV block and sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia, cardiogenic shock and overt or decompensated heart failure; If the treatment is to be discontinued, the dose should be reduced over 1-2 weeks. Since metabolism decreases after birth, the need is re-evaluated.

Approach

1. BP may rise again, especially in the first week; Monitor BP closely during the first week and describe in detail warning signs before discharge, such as headache, visual disturbances, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
2. Hypertension may last up to 4 weeks; Monitor renal function and resolution of proteinuria (complete resolution of significant proteinuria may take weeks to months).
3. Consider cardiology evaluation and ECHO if postpartum hypertension persists or evidence of shortness of breath, chest pain, orthopnea, or pulmonary edema occurs.
4. Explain that the risks of hypertensive disorders in subsequent pregnancies as well as future chronic hypertension, coronary artery disease, stroke, heart failure, chronic kidney disease, type 2 diabetes, and metabolic syndrome are increased.
5. Create a long-term follow-up plan: BP control, weight management, smoking cessation, lipid profile, glucose metabolism and renal function assessment.
6. Note that the risk of VTE is highest in the first 6 weeks after birth; Individualize thromboprophylaxis according to risk stratification.

Treatment

• In severe postpartum hypertension (≥160/110 mmHg), begin without delay: immediate-release oral nifedipine 10–20 mg, IV labetalol 20 mg (over 2 minutes), or IV/IM hydralazine 5 mg; For repeat intervals and upper dose limits, apply 'Acute severe hypertension › Postpartum' in the algorithm.
• In uncomplicated postpartum hypertension — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• In uncomplicated postpartum hypertension — Labetalol (oral): Start at 100 mg twice daily, increasing by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• If labetalol is not available in uncomplicated postpartum hypertension — Metoprolol (oral): start with immediate-release tartrate 50 mg twice daily, gradually increasing according to response; The usual dose during pregnancy is 100 mg twice a day; maximum 200 mg daily, divided into 2 doses; Long-acting succinate is started at 25–100 mg once a day, up to 200 mg once a day.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding; nifedipine, labetalol and metoprolol are compatible with breastfeeding.
• Individualize the threshold for starting oral therapy and the BP target in non-severe postpartum hypertension based on repeated measurements and the clinical picture.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Metoprolol (oral): Not used in second-third degree AV block and sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia, cardiogenic shock and overt or decompensated heart failure; If the treatment is to be discontinued, the dose should be reduced over 1-2 weeks. Since metabolism decreases after birth, the need is re-evaluated.

Approach

1. Confirm new hypertension; inquire about symptoms and evaluate with complete blood count, platelets, creatinine, AST/ALT, bilirubin and quantitative urine protein; Note that preeclampsia can also develop with organ dysfunction without proteinuria.
2. If there are serious findings, evaluate and monitor in hospital.
3. If systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg, confirm by measuring again in 15 minutes; if persistent, initiate rapid-acting antihypertensive as soon as possible, no later than 30–60 minutes; If the BP threshold continues to be exceeded despite consecutive appropriate doses of the selected first-line agent, switch to another first-line agent and seek urgent consultation with a maternal-fetal medicine, anesthesiologist, or intensivist.
4. Describe in detail any warning symptoms before discharge, such as headache, visual disturbance, epigastric or right upper quadrant pain, shortness of breath, chest pain, and sudden worsening of edema.
5. Consider cardiology evaluation and ECHO if postpartum hypertension persists or evidence of shortness of breath, chest pain, orthopnea, or pulmonary edema occurs.
6. If hypertension persists for more than 12 weeks, reassess for chronic hypertension; Include BP control, weight management, smoking cessation, lipid profile, glucose metabolism and kidney function in the long-term follow-up plan.
7. Note that the risk of VTE is highest in the first 6 weeks after birth; Individualize thromboprophylaxis according to risk stratification.

Treatment

• Rapid-acting antihypertensive (IV labetalol, IV hydralazine, or immediate-release oral nifedipine): administer only if systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg confirmed by repeat measurement within 15 minutes; choose one according to contraindications and clinical picture.
• IV labetalol: 20 mg IV over 2 minutes; If BP is above threshold, 40 mg after 10 minutes, then 80 mg every 10 minutes (each dose over 2 minutes); maximum 300 mg total; alternatively, 1–2 mg/min IV infusion.
• Hydralazine: 5 mg IV or IM, followed by 5–10 mg IV every 20–40 minutes if necessary; maximum 20 mg total.
• Immediate-release oral nifedipine: 10–20 mg; Repeat after 20 minutes if necessary; then 10–20 mg every 2–6 hours if necessary; maximum 180 mg per day.
• If BP remains above threshold despite consecutive doses of one agent, switch to the other: IV labetalol after immediate-release nifedipine or hydralazine, IV hydralazine after IV labetalol; If there is no response, seek specialist support for second-line treatment.
• Magnesium sulfate in severe preeclampsia: Give a 4 g IV loading dose over 5–15 minutes, followed by a 1 g/hour IV maintenance infusion for 24 hours.
• Magnesium sulfate in renal dysfunction: if creatinine is 1.0–1.5 mg/dL or urine output is <30 mL/hour for more than 4 hours, keep the maintenance infusion after the loading dose at no more than 1 g/hour and measure serum magnesium every 4 hours; if the level exceeds 9.6 mg/dL (8 mEq/L), stop the infusion, measure every 2 hours, and restart at a lower rate when the level falls below 8.4 mg/dL (7 mEq/L); If creatinine clearance is <30 mL/min, apply intermittent doses according to serum level instead of continuous maintenance infusion and give a total of maximum 20 g in 48 hours.
• In case of magnesium toxicity (loss of reflexes, respiratory depression, PR/QRS prolongation, AV block, bradycardia or hypotension), stop the infusion immediately, support breathing (intubation if necessary) and give 10% calcium gluconate 10 mL (1 g) IV over 3 minutes.
• In uncomplicated postpartum hypertension — Nifedipine (long-acting, oral): Start at 30–60 mg once daily, increasing every 7–14 days; The usual dose is 30–90 mg once a day, maximum 120 mg daily.
• In uncomplicated postpartum hypertension — Labetalol (oral): Start at 100 mg twice daily, increasing by 100 mg (twice daily) every 2–3 days; if necessary, given 3 times a day; maximum 2400 mg per day.
• If labetalol is not available in uncomplicated postpartum hypertension — Metoprolol (oral): start with immediate-release tartrate 50 mg twice daily, gradually increasing according to response; The usual dose during pregnancy is 100 mg twice a day; maximum 200 mg daily, divided into 2 doses; Long-acting succinate is started at 25–100 mg once a day, up to 200 mg once a day.

Note

• Do not use labetalol in asthma, pre-existing myocardial disease, decompensated heart function, heart block, or bradycardia.
• Note that high or frequent doses of hydralazine increase the risk of maternal hypotension.
• Do not puncture or sublingual administration of immediate-release nifedipine capsule.
• Choose postpartum antihypertensive based on clinical presentation and compatibility with breastfeeding; nifedipine, labetalol and metoprolol are compatible with breastfeeding.
• Magnesium sulfate: monitor patellar reflex, respiratory rate, SpO2, and hourly urine output; In case of reflex loss or respiratory depression, stop the infusion and measure serum magnesium. Magnesium is not appropriate in myasthenia gravis, hypocalcemia, moderate to severe renal failure, cardiac ischemia, myocarditis, or heart block (except for first-degree block or the presence of a functioning pacemaker); Select alternative agent with specialist for seizure prevention/treatment.
• Individualize the threshold for starting oral therapy and the BP target in non-severe postpartum hypertension based on repeated measurements and the clinical picture.
• Nifedipine (long-acting, oral): Not given sublingually; The tablet is swallowed whole, not broken, split or chewed; Some patients tolerate better dividing the daily dose into 2 separate applications.
• Labetalol (oral): Avoid in asthma, chronic obstructive pulmonary disease, heart failure, bradycardia (<60/min), or advanced first-degree heart block.
• Metoprolol (oral): Not used in second-third degree AV block and sick sinus syndrome (if there is no functional pacemaker), sinus bradycardia, cardiogenic shock and overt or decompensated heart failure; If the treatment is to be discontinued, the dose should be reduced over 1-2 weeks. Since metabolism decreases after birth, the need is re-evaluated.

Approach

1. Assess the clinical criteria for obstetric APS: at least one unexplained fetal death in a morphologically normal fetus at or after 10+0 weeks; at least one preterm birth before the 34th week due to severe preeclampsia or placental insufficiency; or at least 3 consecutive unexplained spontaneous miscarriages before the 10th week. Laboratory criterion: lupus anticoagulant, medium-high-titer anticardiolipin IgG/IgM (>40 GPL/MPL or >99th percentile), or anti-β2 glycoprotein I IgG/IgM >99th percentile, positive on two occasions at least 12 weeks apart.
2. Consider lupus anticoagulant positivity and triple aPL positivity as indicators of high risk for adverse pregnancy outcome.
3. Measure BP with correct technique and inquire about symptoms at each antenatal visit; The absence of risk factors does not exclude preeclampsia.

Treatment

• Low-dose aspirin: 81–162 mg/day; Start at week 12 and continue until week 36.

Note

• Do not give low-dose aspirin in asthma with a history of allergy to aspirin or other salicylates, NSAID hypersensitivity, nasal polyps, or aspirin-induced bronchospasm. Individualize the decision in cases of history of gastrointestinal bleeding, active peptic ulcer, other foci of gastrointestinal or genitourinary bleeding, or severe liver dysfunction.

Approach

1. Consider lupus anticoagulant positivity and triple aPL positivity as indicators of high risk for adverse pregnancy outcome.
2. Measure BP with correct technique and inquire about symptoms at each antenatal visit; The absence of risk factors does not exclude preeclampsia.
3. Discontinue LMWH before planned delivery.

Treatment

• Low-dose aspirin: 81–162 mg/day; usually start before pregnancy.
• When intrauterine pregnancy is confirmed — Enoxaparin (prophylactic): 40 mg SC once daily for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• Postpartum LMWH: restart 4–6 hours after vaginal delivery, 6–12 hours after cesarean section if there is no significant bleeding and hemostasis is achieved; if neuraxial intervention was performed, start at least 12 hours after the procedure and at least 4 hours after epidural catheter removal; Use whichever of these intervals ends latest; It usually lasts 6 weeks.

Note

• Do not perform neuraxial intervention until at least 12 hours after the last prophylactic dose of LMWH.
• Do not give low-dose aspirin in asthma with a history of allergy to aspirin or other salicylates, NSAID hypersensitivity, nasal polyps, or aspirin-induced bronchospasm. Individualize the decision in cases of history of gastrointestinal bleeding, active peptic ulcer, other foci of gastrointestinal or genitourinary bleeding, or severe liver dysfunction.
• For prophylaxis above 40 mg/day (intermediate dose), evidence is insufficient to define the waiting interval before neuraxial procedures (12–24 hours). Plan timing with the anesthesia team; do not automatically apply the 12-hour rule.
• Aspirin (and other NSAIDs) along with prophylactic LMWH while the epidural catheter is in place may increase the risk of bleeding; Plan catheter removal and resumption of medications with the anesthesia team: remove the catheter at least 12 hours after the last LMWH dose, give the next LMWH dose at least 4 hours after removal.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.

Approach

1. Identify those most likely to benefit from prophylaxis: hereditary or acquired thrombophilia, previous VTE, obesity, long-term immobilization, hypertensive disorder, autoimmune disease, assisted reproductive pregnancy.
2. Individualize thromboprophylaxis according to risk classification, not universally; Reassess VTE risk throughout pregnancy and after birth.
3. Request hereditary thrombophilia testing if there is a personal history of VTE, if it has not been performed previously, and if the result would change antepartum or postpartum management.
4. Determine the interval for stopping anticoagulation before delivery according to thrombotic risk, anticoagulant type and dose, and whether delivery will be induced or by cesarean section.
5. If LMWH is used, wait at least 12 hours after the last prophylactic dose until planned delivery or neuraxial intervention and at least 24 hours after the intermediate or therapeutic dose.
6. Keep in mind that the risk of VTE is highest in the first 6 weeks after birth.

Treatment

• Enoxaparin (prophylactic): 40 mg SC once a day under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance is <30 mL/min or if rapid reversal may be required for labor, neuraxial anesthesia, or emergency surgery in the last weeks of pregnancy, instead of LMWH — UFH (SC, prophylactic): 5000–7500 IU in the 1st trimester, 7500–10 000 IU in the 2nd trimester, 10 000 IU SC every 12 hours in the 3rd trimester (if aPTT is prolonged, the dose is reduced).
• Instead of LMWH for prophylaxis in a history of HIT — Fondaparinux: 2.5 mg SC once a day for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• In active HIT (stop all heparin) or in thrombosis requiring treatment with a history of HIT, treatment dose instead of LMWH — Fondaparinux: 2.5 mg SC once a day for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• If there is no significant bleeding or significant risk of bleeding, restart anticoagulant 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
• If neuraxial block was performed, initiate standard prophylactic dose LMWH at least 12 hours after intervention, intermediate or therapeutic dose LMWH at least 24 hours after intervention, and in any case at least 4 hours after epidural catheter withdrawal; Remove the epidural catheter at least 12 hours after the last standard prophylactic dose and at least 24 hours after the intermediate or therapeutic dose.
• In women who have not had VTE during pregnancy and who do not have an indication for long-term anticoagulant use, continue anticoagulant use for 6 weeks postpartum.

Note

• Do not use VKA (warfarin) and DOAC during pregnancy; Heparins do not cross the placenta.
• Do not use DOACs during breastfeeding; they can pass into breast milk and pose a risk to the baby.
• Limit the use of fondaparinux in pregnancy to severe heparin reactions such as HIT.
• If enoxaparin exceeds 40 mg per day (e.g., 60 mg per day or 40 mg every 12 hours), plan neuraxial intervention and epidural catheter timing with the anesthesia team; do not automatically apply the 12-hour interval used for the standard 40 mg regimen.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.

Approach

1. Evaluate postpartum risk factors: cesarean section, medical comorbidity, preterm birth, stillbirth, hypertension, smoking, preeclampsia or eclampsia, postpartum infection, transfusion.
2. Note that the risk of VTE is highest in the first 6 weeks after birth; Reassess risk after birth and individualize prophylaxis according to risk classification.
3. Request hereditary thrombophilia testing if there is a personal history of VTE, if it has not been performed previously, and if the result would change antepartum or postpartum management.

Treatment

• Enoxaparin (prophylactic): 40 mg SC once a day under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance is <30 mL/min, instead of LMWH — UFH (SC, prophylactic): 5000 IU SC every 8–12 hours after birth.
• Instead of LMWH for prophylaxis in a history of HIT — Fondaparinux: 2.5 mg SC once a day for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• In active HIT (stop all heparin) or in thrombosis requiring treatment with a history of HIT, treatment dose instead of LMWH — Fondaparinux: 2.5 mg SC once a day for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• If there is no significant bleeding or significant risk of bleeding, initiate or restart anticoagulant 4–6 hours after vaginal delivery and 6–12 hours after cesarean section.
• If neuraxial block was performed, initiate standard prophylactic dose LMWH at least 12 hours after intervention, intermediate or therapeutic dose LMWH at least 24 hours after intervention, and in any case at least 4 hours after epidural catheter withdrawal; Remove the epidural catheter at least 12 hours after the last standard prophylactic dose and at least 24 hours after the intermediate or therapeutic dose.
• In women receiving antepartum prophylaxis with prior VTE, high-risk thrombophilia, or thrombophilia together with a family history, continue prophylaxis for 6 weeks postpartum; For prophylaxis initiated solely because of postpartum risk factors, apply for at least 10 days and extend it to up to 6 weeks if the risk factor persists for more than 10 days.

Note

• Avoid estrogen-containing combined hormonal contraception in the event of previous thromboembolism or high-risk prothrombotic status; Progestin-only methods are safer from a thrombotic perspective.
• Do not use DOACs during breastfeeding; they can pass into breast milk and pose a risk to the baby.
• If enoxaparin exceeds 40 mg per day (e.g., 60 mg per day or 40 mg every 12 hours), plan neuraxial intervention and epidural catheter timing with the anesthesia team; do not automatically apply the 12-hour interval used for the standard 40 mg regimen.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.

Approach

1. In cases of negative CUS compatible with clinical evaluation, additional evaluation is generally not performed unless suspicion persists and the examination is not limited to proximal veins only.
2. Maintain clinical monitoring throughout pregnancy.
3. Note that pelvic vein thrombosis may be missed on compression ultrasonography (CUS).

Treatment

• No specific drug treatment is required.

Approach

1. If clinical suspicion persists, repeat CUS on days 3 and 7.
2. Note that pelvic vein thrombosis may be missed on compression ultrasonography (CUS).
3. If iliac vein thrombosis is suspected (swelling in the whole leg, back or hip pain), perform Doppler ultrasonography of the iliac vein; If the result does not support thrombosis, perform MR venography.
4. Maintain clinical monitoring throughout pregnancy.

Treatment

• Therapeutic dose LMWH (enoxaparin): start immediately if DVT is detected on repeat imaging; In cases of suspected iliac vein thrombosis, start while waiting for the results; 1 mg/kg SC every 12 hours based on early pregnancy weight.
• If creatinine clearance <30 mL/min under the same baseline condition, instead of LMWH — UFH (IV, therapeutic): 80 IU/kg IV loading followed by 18 IU/kg/h infusion; aPTT is measured 4–6 hours after challenge, 6 hours after each dose change, and at least daily within the therapeutic range; target aPTT ratio 1.5–2.5 times the average control.
• In the same starting condition, if there is a history of HIT or active HIT, at the treatment dose instead of LMWH — Fondaparinux: 2.5 mg SC once daily for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.

Note

• Do not use VKA (warfarin) and DOAC (dabigatran, rivaroxaban, apixaban, edoxaban) during pregnancy.
• UFH (IV, therapeutic): No loading dose is given after thrombolysis, infusion is started at 18 IU/kg/hour; A loading dose is not given when switching from LMWH, and the infusion is started 1–2 hours before the time of the next LMWH dose. Before neuraxial intervention, the infusion is stopped 4–6 hours and coagulation is evaluated.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.

Approach

1. Plan pregnancy when the disease is clinically inactive for at least 6 months.
2. Note that it is difficult to distinguish a lupus flare from the physiological changes of pregnancy and other pregnancy complications.
3. Note that antiphospholipid antibodies increase the risk of thrombosis through activation of endothelium, platelets, monocytes and complement.
4. State in counseling that there is an increased risk of maternal VTE, hypertensive disorder, preterm birth, unplanned cesarean section, postpartum hemorrhage, acute renal failure, fetal loss, and fetal growth restriction (FGR).
5. Autoimmune disease is in the group that benefits most from thromboprophylaxis; Evaluate VTE risk individually throughout pregnancy and after birth.
6. If LMWH is used, wait at least 12 hours after the last prophylactic dose until planned delivery or neuraxial intervention and at least 24 hours after the intermediate or therapeutic dose.

Treatment

• Low-dose aspirin (81–162 mg/day): Start at week 12, continue through week 36; It is also recommended in aPL positive women.
• If the risk of VTE is increased — Enoxaparin (prophylactic): 40 mg SC once daily for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance is <30 mL/min, instead of LMWH — UFH (SC, prophylactic): 5000–7500 IU in the 1st trimester, 7500–10 000 IU in the 2nd trimester, 10 000 IU SC every 12 hours in the 3rd trimester (dose is reduced if aPTT is prolonged).
• Instead of LMWH for prophylaxis in a history of HIT — Fondaparinux: 2.5 mg SC once a day for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• In active HIT (stop all heparin) or in thrombosis requiring treatment with a history of HIT, treatment dose instead of LMWH — Fondaparinux: 2.5 mg SC once a day for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• If there is no significant bleeding or significant risk of bleeding, restart anticoagulant 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
• If neuraxial block was performed, initiate standard prophylactic dose LMWH at least 12 hours after intervention, intermediate or therapeutic dose LMWH at least 24 hours after intervention, and in any case at least 4 hours after epidural catheter withdrawal; Remove the epidural catheter at least 12 hours after the last standard prophylactic dose and at least 24 hours after the intermediate or therapeutic dose.

Note

• Do not use VKA (warfarin) and DOAC during pregnancy; If anticoagulant is required, use heparin, which does not cross the placenta.
• Do not use DOACs during breastfeeding; they can pass into breast milk and pose a risk to the baby.
• If enoxaparin exceeds 40 mg per day (e.g., 60 mg per day or 40 mg every 12 hours), plan neuraxial intervention and epidural catheter timing with the anesthesia team; do not automatically apply the 12-hour interval used for the standard 40 mg regimen.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.

Approach

1. Plan pregnancy when the disease is clinically inactive for at least 6 months.
2. Note that it is difficult to distinguish a lupus flare from the physiological changes of pregnancy and other pregnancy complications.
3. Verify at least one of the following obstetric criteria after other causes have been excluded: at least three consecutive unexplained pregnancy losses before the 10th week; At least one unexplained death in a morphologically normal fetus at 10+0 weeks or later; birth before the 34th week due to severe preeclampsia, eclampsia, or placental insufficiency.
4. Confirm the laboratory criterion on two tests at least 12 weeks apart: positive lupus anticoagulant (LA), or moderate-to-high-titer (>40 GPL/MPL or >99th percentile) IgG/IgM anticardiolipin, or IgG/IgM anti-β2 glycoprotein I above the 99th percentile; do not count isolated low-titer positivity alone as an APS laboratory criterion.
5. Note that LA positivity and triple aPL positivity predict poor pregnancy outcome.
6. Note that concomitant APS significantly increases the risk of arterial and venous thrombosis.
7. State in counseling that there is an increased risk of maternal VTE, hypertensive disorder, preterm birth, unplanned cesarean section, postpartum hemorrhage, acute renal failure, fetal loss, and fetal growth restriction (FGR).
8. Wait at least 12 hours after the last prophylactic dose of LMWH until planned delivery or neuraxial intervention.

Treatment

• Low-dose aspirin (81–162 mg/day): usually start before pregnancy as it is accompanied by obstetric APS.
• Add when intrauterine pregnancy is confirmed — Enoxaparin (prophylactic): 40 mg SC once daily for under 100 kg; 60 mg SC for 100–129 kg, 80 mg SC for 130–169 kg once daily (can be divided into 2 doses); 0.6 mg/kg/day SC for 170 kg and above (can be divided into 2 doses).
• If creatinine clearance is <30 mL/min, instead of LMWH — UFH (SC, prophylactic): 5000–7500 IU in the 1st trimester, 7500–10 000 IU in the 2nd trimester, 10 000 IU SC every 12 hours in the 3rd trimester (dose is reduced if aPTT is prolonged).
• Instead of LMWH for prophylaxis in a history of HIT — Fondaparinux: 2.5 mg SC once a day for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• In active HIT (stop all heparin) or in thrombosis requiring treatment with a history of HIT, treatment dose instead of LMWH — Fondaparinux: 2.5 mg SC once a day for prophylaxis; In active HIT or thrombosis requiring treatment, 5 mg under 50 kg, 7.5 mg in 50–100 kg, 10 mg SC once a day over 100 kg.
• If there is no significant bleeding or significant risk of bleeding, restart anticoagulant 4–6 hours after vaginal birth and 6–12 hours after cesarean section.
• If neuraxial block was performed, initiate standard prophylactic dose LMWH at least 12 hours after intervention, intermediate or therapeutic dose LMWH at least 24 hours after intervention, and in any case at least 4 hours after epidural catheter withdrawal; Remove the epidural catheter at least 12 hours after the last standard prophylactic dose and at least 24 hours after the intermediate or therapeutic dose.
• Continue LMWH for 6 weeks postpartum in women who have not had VTE during pregnancy and who do not have an indication for long-term anticoagulant use.

Note

• Do not use VKA (warfarin) and DOAC during pregnancy.
• Do not use DOACs during breastfeeding; they can pass into breast milk and pose a risk to the baby.
• If enoxaparin exceeds 40 mg per day (e.g., 60 mg per day or 40 mg every 12 hours), plan neuraxial intervention and epidural catheter timing with the anesthesia team; do not automatically apply the 12-hour interval used for the standard 40 mg regimen.
• Enoxaparin (prophylactic): If the daily dose exceeds 40 mg, the timing of neuraxial intervention is planned as for intermediate dose prophylaxis: there is insufficient data to recommend a specific waiting period between 12 and 24 hours, the 12-hour rule is not automatically applied. If creatinine clearance is below 30 mL/min, the prophylactic dose is 30 mg SC once a day.
• UFH (SC, prophylactic): before neuraxial procedures or catheter removal, wait 4–6 hours after the last dose of 5000 IU given 2–3 times daily, or assess coagulation; for 7500–10,000 IU twice daily, wait 12 hours after the last dose and assess coagulation; if a single dose exceeds 10,000 IU or the total daily dose exceeds 20,000 IU, wait at least 24 hours after the last dose and confirm that aPTT is normal. The next SC UFH dose may be given 1 hour after the procedure or catheter removal. If UFH has been used for more than 4 days, check the platelet count before the procedure or catheter removal.
• Fondaparinux: Contraindicated with creatinine clearance below 30 mL/min; Prophylactic use is contraindicated in adults with a body weight below 50 kg, the risk of bleeding increases with low weight; elimination half-life is 17–21 hours; The optimal time between administration and neuraxial intervention is unknown; LMWH's 12/24 hour waiting intervals do not apply to fondaparinux; Benefits and risks are weighed before neuraxial intervention.

Approach

1. Predetermine, document, and explain the perinatal anticoagulant plan to the patient with the obstetrics, anesthesia, and hematology teams.
2. Discontinue anticoagulant usually 12–24 hours before planned delivery to limit maternal bleeding and neuraxial hematoma; Determine the interval according to thrombotic risk, type and dose of anticoagulant, and whether the birth will be by induction or cesarean section.
3. Take advantage of UFH as rapid reversal may be required in the last weeks of pregnancy; LMWH is preferred except for the last weeks.
4. Keep in mind that the risk of VTE is highest in the first 6 weeks after birth.

Treatment

• Wait at least 12 hours after the last prophylactic dose of LMWH until planned delivery or neuraxial intervention.
• If there is no significant bleeding or significant risk of bleeding, restart anticoagulant 4–6 hours after vaginal delivery.
• If neuraxial block was performed, initiate standard prophylactic dose LMWH at least 12 hours after intervention, intermediate or therapeutic dose LMWH at least 24 hours after intervention, and in any case at least 4 hours after epidural catheter withdrawal; Remove the epidural catheter at least 12 hours after the last standard prophylactic dose and at least 24 hours after the intermediate or therapeutic dose.
• In women who have not had VTE during pregnancy and who do not have an indication for long-term anticoagulant use, continue anticoagulant use for 6 weeks postpartum.

Note

• Do not use DOACs during breastfeeding; they can pass into breast milk and pose a risk to the baby.
• If enoxaparin exceeds 40 mg per day (e.g., 60 mg per day or 40 mg every 12 hours), plan neuraxial intervention and epidural catheter timing with the anesthesia team; do not automatically apply the 12-hour interval used for the standard 40 mg regimen.

Approach

1. Predetermine, document, and explain the perinatal anticoagulant plan to the patient with the obstetrics, anesthesia, and hematology teams.
2. Discontinue anticoagulant usually 12–24 hours before planned delivery to limit maternal bleeding and neuraxial hematoma; Determine the interval according to thrombotic risk, type and dose of anticoagulant, and whether the birth will be by induction or cesarean section.
3. Take advantage of UFH as rapid reversal may be required in the last weeks of pregnancy; LMWH is preferred except for the last weeks.
4. Keep in mind that the risk of VTE is highest in the first 6 weeks after birth.

Treatment

• Wait at least 12 hours after the last prophylactic dose of LMWH until planned delivery or neuraxial intervention.
• If there is no significant bleeding or significant risk of bleeding, restart anticoagulant 6–12 hours after cesarean section.
• If neuraxial block was performed, initiate standard prophylactic dose LMWH at least 12 hours after intervention, intermediate or therapeutic dose LMWH at least 24 hours after intervention, and in any case at least 4 hours after epidural catheter withdrawal; Remove the epidural catheter at least 12 hours after the last standard prophylactic dose and at least 24 hours after the intermediate or therapeutic dose.
• In women who have not had VTE during pregnancy and who do not have an indication for long-term anticoagulant use, continue anticoagulant use for 6 weeks postpartum.

Note

• Do not use DOACs during breastfeeding; they can pass into breast milk and pose a risk to the baby.
• If enoxaparin exceeds 40 mg per day (e.g., 60 mg per day or 40 mg every 12 hours), plan neuraxial intervention and epidural catheter timing with the anesthesia team; do not automatically apply the 12-hour interval used for the standard 40 mg regimen.

Approach

1. Predetermine, document, and explain the perinatal anticoagulant plan to the patient with the obstetrics, anesthesia, and hematology teams.
2. Discontinue anticoagulant usually 12–24 hours before planned delivery to limit maternal bleeding and neuraxial hematoma; Determine the interval according to thrombotic risk, type and dose of anticoagulant, and whether the birth will be by induction or cesarean section.
3. Take advantage of UFH as rapid reversal may be required in the last weeks of pregnancy; LMWH is preferred except for the last weeks.
4. Keep in mind that the risk of VTE is highest in the first 6 weeks after birth.

Treatment

• Wait at least 24 hours after the last intermediate or therapeutic dose of LMWH until planned delivery or neuraxial intervention.
• If there is no significant bleeding or significant risk of bleeding, restart anticoagulant 4–6 hours after vaginal delivery.
• If neuraxial block was performed, initiate standard prophylactic dose LMWH at least 12 hours after intervention, intermediate or therapeutic dose LMWH at least 24 hours after intervention, and in any case at least 4 hours after epidural catheter withdrawal; Remove the epidural catheter at least 12 hours after the last standard prophylactic dose and at least 24 hours after the intermediate or therapeutic dose.
• In women who have not had VTE during pregnancy and who do not have an indication for long-term anticoagulant use, continue anticoagulant use for 6 weeks postpartum.
• In women who have experienced acute VTE during pregnancy, continue postpartum for at least 6 weeks and a total treatment duration of at least 3 months; If there is an indication for permanent/chronic anticoagulation, do not discontinue the treatment at the 6th week and continue according to the underlying indication.

Note

• Do not use DOACs during breastfeeding; they can pass into breast milk and pose a risk to the baby.

Approach

1. Predetermine, document, and explain the perinatal anticoagulant plan to the patient with the obstetrics, anesthesia, and hematology teams.
2. Discontinue anticoagulant usually 12–24 hours before planned delivery to limit maternal bleeding and neuraxial hematoma; Determine the interval according to thrombotic risk, type and dose of anticoagulant, and whether the birth will be by induction or cesarean section.
3. Take advantage of UFH as rapid reversal may be required in the last weeks of pregnancy; LMWH is preferred except for the last weeks.
4. Keep in mind that the risk of VTE is highest in the first 6 weeks after birth.

Treatment

• Wait at least 24 hours after the last intermediate or therapeutic dose of LMWH until planned delivery or neuraxial intervention.
• If there is no significant bleeding or significant risk of bleeding, restart anticoagulant 6–12 hours after cesarean section.
• If neuraxial block was performed, initiate standard prophylactic dose LMWH at least 12 hours after intervention, intermediate or therapeutic dose LMWH at least 24 hours after intervention, and in any case at least 4 hours after epidural catheter withdrawal; Remove the epidural catheter at least 12 hours after the last standard prophylactic dose and at least 24 hours after the intermediate or therapeutic dose.
• In women who have not had VTE during pregnancy and who do not have an indication for long-term anticoagulant use, continue anticoagulant use for 6 weeks postpartum.
• In women who have experienced acute VTE during pregnancy, continue postpartum for at least 6 weeks and a total treatment duration of at least 3 months; If there is an indication for permanent/chronic anticoagulation, do not discontinue the treatment at the 6th week and continue according to the underlying indication.

Note

• Do not use DOACs during breastfeeding; they can pass into breast milk and pose a risk to the baby.

Approach

1. Predetermine, document, and explain the perinatal anticoagulant plan to the patient with the obstetrics, anesthesia, and hematology teams.
2. Discontinue therapeutic IV UFH infusion 4–6 hours before planned delivery or neuraxial intervention; Confirm aPTT has returned to normal prior to intervention.
3. Keep in mind that the risk of VTE is highest in the first 6 weeks after birth.
4. If UFH use exceeds four days, check platelet count before neuraxial intervention or epidural catheter withdrawal.

Treatment

• Perform neuraxial intervention after aPTT returns to normal; Normalization usually takes approximately 6 hours after the therapeutic IV infusion is discontinued.
• If there is no significant bleeding or significant risk of bleeding, restart anticoagulant 4–6 hours after vaginal delivery.
• If neuraxial block was performed and there is no evidence of postpartum hemorrhage, initiate UFH at least 1 hour after the procedure and epidural catheter removal.
• If the procedure was traumatic, initiate therapeutic anticoagulation at least 24 hours after catheter removal.
• If switching to LMWH after birth, start the standard prophylactic dose at least 12 hours after the intervention, the intermediate or therapeutic dose at least 24 hours after the procedure, and in any case at least 4 hours after the epidural catheter is removed.
• In women who have not had VTE during pregnancy and who do not have an indication for long-term anticoagulant use, continue anticoagulant use for 6 weeks postpartum.
• In women who have experienced acute VTE during pregnancy, continue postpartum for at least 6 weeks and a total treatment duration of at least 3 months; If there is an indication for permanent/chronic anticoagulation, do not discontinue the treatment at the 6th week and continue according to the underlying indication.

Note

• Do not use DOACs during breastfeeding; they can pass into breast milk and pose a risk to the baby.

Approach

1. Predetermine, document, and explain the perinatal anticoagulant plan to the patient with the obstetrics, anesthesia, and hematology teams.
2. Discontinue therapeutic IV UFH infusion 4–6 hours before planned delivery or neuraxial intervention; Confirm aPTT has returned to normal prior to intervention.
3. Keep in mind that the risk of VTE is highest in the first 6 weeks after birth.
4. If UFH use exceeds four days, check platelet count before neuraxial intervention or epidural catheter withdrawal.

Treatment

• Perform neuraxial intervention after aPTT returns to normal; Normalization usually takes approximately 6 hours after the therapeutic IV infusion is discontinued.
• If there is no significant bleeding or significant risk of bleeding, restart anticoagulant 6–12 hours after cesarean section.
• If neuraxial block was performed and there is no evidence of postpartum hemorrhage, initiate UFH at least 1 hour after the procedure and epidural catheter removal.
• If the procedure was traumatic, initiate therapeutic anticoagulation at least 24 hours after catheter removal.
• If switching to LMWH after birth, start the standard prophylactic dose at least 12 hours after the intervention, the intermediate or therapeutic dose at least 24 hours after the procedure, and in any case at least 4 hours after the epidural catheter is removed.
• In women who have not had VTE during pregnancy and who do not have an indication for long-term anticoagulant use, continue anticoagulant use for 6 weeks postpartum.
• In women who have experienced acute VTE during pregnancy, continue postpartum for at least 6 weeks and a total treatment duration of at least 3 months; If there is an indication for permanent/chronic anticoagulation, do not discontinue the treatment at the 6th week and continue according to the underlying indication.

Note

• Do not use DOACs during breastfeeding; they can pass into breast milk and pose a risk to the baby.

Approach

1. Predetermine, document, and explain the perinatal anticoagulant plan to the patient with the obstetrics, anesthesia, and hematology teams.
2. Discontinue UFH according to dosage before planned delivery to limit maternal bleeding and neuraxial hematoma; Determine the interval according to thrombotic risk and whether the birth will be by induction or cesarean section.
3. Keep in mind that the risk of VTE is highest in the first 6 weeks after birth.
4. If UFH use exceeds four days, check platelet count before neuraxial intervention or epidural catheter withdrawal.

Treatment

• Perform neuraxial intervention after aPTT returns to normal; Normalization may take up to 24 hours after subcutaneous administration.
• If subcutaneous UFH 5,000 units is used two or three times daily, wait at least 4–6 hours after the last dose for neuraxial intervention or evaluate coagulation; If 7,500–10,000 units are used twice daily, wait at least 12 hours and assess coagulation; If >10,000 units per dose or >20,000 units per day, wait at least 24 hours and verify aPTT is normal.
• If there is no significant bleeding or significant risk of bleeding, restart anticoagulant 4–6 hours after vaginal delivery.
• If neuraxial block was performed and there is no evidence of postpartum hemorrhage, initiate UFH at least 1 hour after intervention and epidural catheter removal; If low-dose SC UFH is used, remove the catheter at least 4–6 hours after the last dose.
• If the procedure was traumatic, initiate therapeutic anticoagulation at least 24 hours after catheter removal.
• If switching to LMWH after birth, start the standard prophylactic dose at least 12 hours after the intervention, the intermediate or therapeutic dose at least 24 hours after the procedure, and in any case at least 4 hours after the epidural catheter is removed.
• In women who have not had VTE during pregnancy and who do not have an indication for long-term anticoagulant use, continue anticoagulant use for 6 weeks postpartum.
• In women who have experienced acute VTE during pregnancy, continue postpartum for at least 6 weeks and a total treatment duration of at least 3 months; If there is an indication for permanent/chronic anticoagulation, do not discontinue the treatment at the 6th week and continue according to the underlying indication.

Note

• Do not use DOACs during breastfeeding; they can pass into breast milk and pose a risk to the baby.

Approach

1. Predetermine, document, and explain the perinatal anticoagulant plan to the patient with the obstetrics, anesthesia, and hematology teams.
2. Discontinue UFH according to dosage before planned delivery to limit maternal bleeding and neuraxial hematoma; Determine the interval according to thrombotic risk and whether the birth will be by induction or cesarean section.
3. Keep in mind that the risk of VTE is highest in the first 6 weeks after birth.
4. If UFH use exceeds four days, check platelet count before neuraxial intervention or epidural catheter withdrawal.

Treatment

• Perform neuraxial intervention after aPTT returns to normal; Normalization may take up to 24 hours after subcutaneous administration.
• If subcutaneous UFH 5,000 units is used two or three times daily, wait at least 4–6 hours after the last dose for neuraxial intervention or evaluate coagulation; If 7,500–10,000 units are used twice daily, wait at least 12 hours and assess coagulation; If >10,000 units per dose or >20,000 units per day, wait at least 24 hours and verify aPTT is normal.
• If there is no significant bleeding or significant risk of bleeding, restart anticoagulant 6–12 hours after cesarean section.
• If neuraxial block was performed and there is no evidence of postpartum hemorrhage, initiate UFH at least 1 hour after intervention and epidural catheter removal; If low-dose SC UFH is used, remove the catheter at least 4–6 hours after the last dose.
• If the procedure was traumatic, initiate therapeutic anticoagulation at least 24 hours after catheter removal.
• If switching to LMWH after birth, start the standard prophylactic dose at least 12 hours after the intervention, the intermediate or therapeutic dose at least 24 hours after the procedure, and in any case at least 4 hours after the epidural catheter is removed.
• In women who have not had VTE during pregnancy and who do not have an indication for long-term anticoagulant use, continue anticoagulant use for 6 weeks postpartum.
• In women who have experienced acute VTE during pregnancy, continue postpartum for at least 6 weeks and a total treatment duration of at least 3 months; If there is an indication for permanent/chronic anticoagulation, do not discontinue the treatment at the 6th week and continue according to the underlying indication.

Note

• Do not use DOACs during breastfeeding; they can pass into breast milk and pose a risk to the baby.