In a groundbreaking development in maternal-fetal medicine, the Society for Maternal-Fetal Medicine (SMFM) has unveiled new, comprehensive guidelines aimed at improving the diagnosis and management of heart failure in pregnant and postpartum patients. Published in the esteemed journal Pregnancy, these guidelines emphasize the crucial role of prepregnancy counseling, multidisciplinary care teams, and referrals to specialized centers, aiming to optimize both maternal and neonatal health outcomes. Heart failure, a condition characterized by the heart’s inability to pump blood efficiently, represents a significant and growing concern in pregnancy-related healthcare due to its substantial contribution to maternal morbidity and mortality worldwide.
Heart disease remains the leading cause of pregnancy-related death in the United States, with a disproportionate impact on non-Hispanic Black populations. The complex interplay between cardiovascular disease and pregnancy poses unique clinical challenges, as physiological changes during gestation can exacerbate existing cardiac dysfunction or precipitate new-onset heart failure. SMFM’s Consult Series #73 recognizes the heterogeneous nature of heart failure, which may involve dysfunction in the left ventricle, right ventricle, or both, and calls for tailored diagnostic and therapeutic approaches based on individual patient profiles, ventricular involvement, and whether the condition is acute or chronic.
Current clinical practice is often complicated by the overlapping symptomatology of heart failure and normal pregnancy, as symptoms such as fatigue and dyspnea are common in both scenarios. This ambiguity can delay diagnosis and management, increasing risks to both mother and fetus. SMFM’s expert panel highlights the paramount importance of early and precise identification of heart failure, recommending that all patients with known cardiac pathology receive comprehensive risk stratification either prior to conception or in early pregnancy. This strategic approach facilitates timely interventions and informed decision-making for contraceptive planning, pregnancy continuation, or termination when necessary.
The guidelines controversially but pragmatically address patients with severe pulmonary arterial hypertension and those exhibiting significantly impaired left ventricular function, particularly with ejection fractions below 30%. For these high-risk groups, offering abortion care is a critical counseling component, supplemented by robust support for those electing to carry pregnancies to term. SMFM underscores the indispensability of specialized Pregnancy Heart Teams, composed of obstetricians, cardiologists, anesthesiologists, and intensive care specialists, to navigate these complex clinical trajectories and coordinate high-stakes care delivery.
Pharmacological management during pregnancy necessitates a delicate balance between maternal benefit and fetal safety, a task complicated by the teratogenic potential and postpartum compatibility of various cardiovascular medications. The new recommendations advocate for the discontinuation of certain agents, such as sodium-glucose cotransporter inhibitors (SGLT2i), spironolactone, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and angiotensin receptor-neprilysin inhibitors (ARNis), due to their adverse fetal effects. These drugs are to be replaced with safer alternatives, including vasodilators like hydralazine, while continuation of beta-adrenergic blockers, including metoprolol and carvedilol, remains encouraged given their established safety profiles in pregnancy.
Breastfeeding introduces additional complexities in medication safety. The comprehensive guidelines recommend cautious use of ACE inhibitors, ARBs, aldosterone antagonists, and SGLT2i during lactation due to potential risks to the neonate. These recommendations demand vigilant pharmacovigilance and tailored counseling to ensure maternal adherence to lifesaving regimens while minimizing neonatal exposure, thereby safeguarding the delicate balance of postpartum maternal-infant health.
Delivery planning constitutes a critical phase in the continuum of care for pregnant patients with heart failure. SMFM advocates for meticulous team-based planning involving multiple specialties, including maternal-fetal medicine, cardiology, anesthesiology, and nursing. The goal is to achieve term delivery wherever clinically feasible, prioritizing vaginal birth unless obstetric indications necessitate cesarean section. This approach aims to mitigate peripartum cardiovascular stress while optimizing neonatal outcomes, reflecting an integration of obstetric and cardiac expertise.
Postpartum care is identified as a vulnerable period, frequently marked by rapid cardiovascular shifts and heightened maternal mortality risk. The guidelines emphasize that many cardiac-related deaths and severe complications manifest after hospital discharge, underscoring the necessity for close postpartum surveillance and outpatient follow-up. Counseling regarding infant feeding and continuation or modification of cardiac medications within the context of breastfeeding forms a cornerstone of this vigilant postpartum strategy.
Importantly, the guidance delves into the nuances of managing patients with peripartum cardiomyopathy, a pregnancy-associated dilated cardiomyopathy that may fully resolve or persist postpartum. Recommendations advocate for individualized counseling on future pregnancy risks, focusing on recurrence rates and severity, offering women vital insights to make informed reproductive decisions. This patient-centered model epitomizes the recent evolution in maternal-fetal care towards multidisciplinary, precision medicine paradigms.
The SMFM Consult Series #73 emerges as a meticulously compiled synthesis of current evidence, supported by the Heart Rhythm Society, designed to inform and transform clinical practice. It embodies an urgent response to the mounting challenge of cardiovascular disease in pregnancy, blending systematic review methodologies with expert consensus. As cardiovascular disease continues to rise globally, these guidelines promise to serve as a template for institutions and clinicians committed to reducing maternal mortality and morbidity from heart failure.
In conclusion, the Society for Maternal-Fetal Medicine’s latest recommendations deliver a pivotal roadmap for improving the care of pregnant and postpartum patients with heart failure. Through early risk assessment, nuanced pharmacotherapy, multidisciplinary delivery planning, and close postpartum monitoring, these guidelines address a critical gap in maternal healthcare. With heart disease disproportionately afflicting marginalized populations, this initiative also represents a meaningful step towards equity in maternal health outcomes. As awareness grows and implementation progresses, the clinical community anticipates these recommendations to catalyze advances in both research and practice, ultimately elevating the standard of care for this high-risk population.
Subject of Research: People
Article Title: Society for Maternal-Fetal Medicine Consult Series #73: Diagnosis and management of right and left heart failure during pregnancy and postpartum
News Publication Date: 22-Sep-2025
Web References:
https://obgyn.onlinelibrary.wiley.com/doi/10.1002/pmf2.70059
Keywords: Prenatal care, Postnatal care, Prenatal screening
