This handout is for acute hf — peripartum cardiomyopathy (ppcm). Your care team identified this based on: new dyspnea/orthopnea/pnd in last month of pregnancy through 5 months postpartum.
Other reasons your team may use this plan: echo lvef <45% in peripartum window with no prior cardiac history (ppcm diagnostic criterion); bnp/nt-probnp elevated in peripartum patient with dyspnea (bnp elevation not physiologic in pregnancy); history of ppcm with subsequent pregnancy — recurrence risk 30-50% if lvef did not normalize.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| furosemide | 40 mg IV bolus then 5-10 mg/h infusion or 40-80 mg IV q6-8h | IV | as scheduled | DOSE PMID 21366472 high-dose IV bolus arm; safe pregnancy and lactation |
| hydralazine | 10-25 mg PO TID OR 5-10 mg IV q4-6h prn | PO/IV | TID | Pregnancy-safe afterload reducer; substitute for ACEi/ARB during pregnancy (V-HeFT-I + ESC pregnancy 2018 PMID 30165544) |
| isosorbide dinitrate | 20-40 mg PO TID | PO | TID | Combine with hydralazine (A-HeFT analog) for pregnancy-safe afterload + preload reduction; ESC pregnancy 2018 |
| metoprolol succinate | 12.5-25 mg PO daily titrate | PO | daily | BB safe in pregnancy and lactation; preferred BB in PPCM (CIBIS / MERIT-HF extrapolation; ACC/AHA 2022 HF Class I) |
| carvedilol | 3.125 mg PO BID titrate | PO | BID | CAPRICORN PMID 11356436 + COPERNICUS PMID 11386262; preferred postpartum (limited lactation data but acceptable per AAP) |
| sacubitril-valsartan | 24/26 mg PO BID titrate to 97/103 BID | PO | BID | PIONEER-HF PMID 30403955; POSTPARTUM ONLY (TERATOGENIC — Pregnancy Category D); AAP advises against during lactation |
| enalapril | 2.5 mg PO BID titrate | PO | BID | POSTPARTUM ONLY; enalapril and captopril are AAP-approved during lactation (low milk transfer); ACC/AHA 2022 HF |
| spironolactone | 12.5-25 mg PO daily | PO | daily | POSTPARTUM ONLY (potential antiandrogenic teratogen); RALES PMID 10471456 |
| empagliflozin | 10 mg PO daily | PO | daily | EMPULSE PMID 35347356; POSTPARTUM ONLY; not recommended during pregnancy or breastfeeding (animal data + limited human data) |
| bromocriptine | 2.5 mg PO BID × 2 weeks then 2.5 mg PO daily × 6 weeks (8 weeks total) | PO | BID then daily | IPAC RCT (Sliwa 2017 PMID 28637825): bromocriptine 8-week regimen improved LVEF recovery from 27→58% at 6 mo; POSTPARTUM ONLY (suppresses lactation); add prophylactic AC during therapy due to thrombosis risk |
| enoxaparin | 1 mg/kg SC q12h (therapeutic) OR 40 mg SC daily (prophylactic) | SC | q12h or daily | LMWH preferred peripartum (warfarin teratogenic 6-12 weeks gestation + fetal bleeding third trimester); ESC pregnancy 2018 PMID 30165544; therapeutic for AC indication, prophylactic during bromocriptine |
| warfarin | 5 mg PO daily; INR target 2-3 | PO | daily | POSTPARTUM transition from LMWH; safe in lactation (no significant breast milk transfer) |
| apixaban | 5 mg PO BID | PO | BID | POSTPARTUM alternative to warfarin; NOT recommended during breastfeeding (limited data); preferred for AF or LV thrombus per AHA 2022 |
Plan: PPCM pregnancy-aware ADHF — substitutes hydralazine/nitrate for ACEi peripartum; adds bromocriptine postpartum per IPAC; LMWH peripartum, warfarin/DOAC postpartum
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
PPCM clinic at 2 weeks, 6 weeks, 3 months, 6 months postpartum; serial echo for heart pumping strength (LVEF) recovery; future-pregnancy counseling (recurrence 30-50% if heart pumping strength (LVEF) did not normalize); ICD/WCD evaluation if heart pumping strength (LVEF) still <35% at 3-6 months on full the four foundational heart-failure medications
Guideline: AHA 2020 PPCM Scientific Statement + ESC pregnancy 2018 + 2022 ACC/AHA HF + IPAC RCT 2017