Use of medication for cardiovascular disease during pregnancy

Key Points

  • The physiological changes of pregnancy result in changes to the pharmacokinetics of many drugs used for the treatment of cardiovascular disease, often necessitating an increase in dosage

  • Avoiding necessary medication for fear of teratogenicity threatens both mother and fetus, and is often a worse option than accepting the small increase in fetal risk related to the medication

  • Most drugs for cardiovascular disease can be used safely during pregnancy; exceptions include high-dose warfarin during the first trimester, angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers, amiodarone, and spironolactone

  • Anticoagulation in pregnant women with mechanical heart valves is complex, and these women need expert care in specialized centres throughout their pregnancies

  • Cardiologists should be able to advise obstetricians about the safe use of tocolytic and uterotonic drugs in patients with cardiovascular disease

Abstract

One-third of women with heart disease use medication for the treatment of cardiovascular disease (CVD) during pregnancy. Increased plasma volume, renal clearance, and liver enzyme activity in pregnant women change the pharmacokinetics of these drugs, often resulting in the need for an increased dose. Fetal well-being is a major concern among pregnant women. Fortunately, many drugs used to treat CVD can be used safely during pregnancy, with the exception of high-dose warfarin in the first trimester, angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers, amiodarone, and spironolactone. A timely and thorough discussion between the cardiologist and the pregnant patient about the potential benefits and adverse effects of medication for CVD is important. Noncompliance with necessary treatment for cardiovascular disorders endangers not only the mother, but also the fetus. This Review is an overview of the pharmacokinetic changes in medications for CVD during pregnancy and the safety of these drugs for the fetus. The implications for maternal treatment are discussed. The Review also includes a short section on the cardiovascular effects of medication used for obstetric indications.

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Figure 1
Figure 2: Haemodynamic changes during pregnancy.22,23,126
Figure 3: Effects of cardiovascular medication on the fetus.

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Pieper, P. Use of medication for cardiovascular disease during pregnancy. Nat Rev Cardiol 12, 718–729 (2015). https://doi.org/10.1038/nrcardio.2015.172

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