New SMFM Guidance Addresses Heart failure in Pregnancy and Postpartum
The Society for Maternal-Fetal Medicine (SMFM) has recently released updated guidance for clinicians on the diagnosis and management of heart failure during pregnancy and the postpartum period. The recommendations, published in Pregnancy and announced via Eurekalert on October 3, 2025, emphasize individualized patient care and proactive risk assessment.
The guidance highlights the importance of thorough pre-conception counseling, notably for patients with severe pulmonary arterial hypertension or a left ventricular ejection fraction below 30%, informing them of the significant risks of morbidity and mortality.Importantly, SMFM stresses that abortion care should be accessible to all patients with heart failure, irrespective of disease severity, as a component of thorough counseling and informed decision-making.
For individuals with a history of peripartum cardiomyopathy,future pregnancy decisions should be made on a case-by-case basis. Patients who have experienced full recovery of ventricular function should be counseled regarding the potential for recurrence and the possible severity of heart failure should it return.
A key focus of the new guidance is medication management. Clinicians are advised to meticulously review medication compatibility before conception and throughout pregnancy. Several medications are specifically recommended for discontinuation or avoidance due to teratogenic effects or safety concerns, including sodium-glucose cotransporter inhibitors (SGLT2i), spironolactone, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and angiotensin receptor-neprilysin inhibitors (ARNi).Alternatives like hydralazine, isosorbide dinitrate (for afterload reduction), and furosemide (for diuresis) are suggested for acute left ventricular heart failure. Beta-blockers - specifically metoprolol, carvedilol, and bisoprolol - are generally recommended for continuation when clinically appropriate. During acute decompensated heart failure in pregnancy, inotropic blockade with beta-blockers is not advised, and prophylactic anticoagulation is recommended for hospitalized patients with acute left ventricular dysfunction. Postpartum, ACE inhibitors, ARBs, or ARNi can be considered for afterload reduction, provided there are no contraindications.
The SMFM guidance also stresses a multidisciplinary approach to delivery planning, involving obstetrics, maternal-fetal medicine, cardiology, anesthesiology, and nursing. Planned vaginal delivery at term is recommended for most stable patients, reserving cesarean delivery for specific obstetric indications. Neuraxial anesthesia is favored for pain management and to minimize hemodynamic stress during labour.
Postpartum care is identified as a particularly vulnerable period due to significant cardiovascular volume shifts. The guidance emphasizes the need for close inpatient monitoring,individualized discharge planning,and early follow-up to reduce the risk of postpartum cardiac complications. routine counseling on infant feeding practices should be provided, with a review of medication compatibility; ACE inhibitors are considered compatible with breastfeeding, while caution is advised for ARBs, aldosterone antagonists, and SGLT2 inhibitors due to limited neonatal safety data.
References:
- Society for Maternal-Fetal Medicine. SMFM issues new guidance on diagnosing and managing heart failure during pregnancy and postpartum.Eurekalert. October 3, 2025. Accessed October 7, 2025. https://www.eurekalert.org/news-releases/1100779
- Hameed AB, Licon E, Vaught AJ, Shree R. Society for maternal‐Fetal Medicine Consult Series #73: Diagnosis and management of right and left heart failure during pregnancy and postpartum. Pregnancy. 2025;1(5). doi:https://doi.org/10.1002/pmf2.70059
