For treatment of chronic heart failure the pregnancy status of the patient is important. Patients can be peri- or postpartum. Women who present with heart failure during pregnancy require joint cardiac and obstetric care. Possible adverse effects on the fetus must be considered when prescribing drugs (Fig. 2; Tables 2 and 3).

Heart failure should be treated according to guidelines on acute and chronic heart failure (Gheorghiade et al. 2010). The principal objectives in the management of heart failure are to make patients feel better, reduce hospitalisations (new and recurrent) and to prolong survival. Drugs such as diuretics and digoxin improve symptoms. Beta-blockers, ACE-inhibitors and aldosterone antagonists improve survival. It is now recognized that preventing HF hospitalisation is important for patients and healthcare systems.

Data on the use of medications in pregnancy are limited as pharmaceutical studies often exclude pregnant women due to fear of litigation if fetal effects occur. Evidence is therefore limited and for most medication only a ‘class C’ (Consensus of opinion of experts and/or small studies, retrospective studies or registries) (Regitz-Zagrosek et al. 2011) is available. Levels of evidence on the recommendations for the management of cardiomyopathies and heart failure in pregnancy is summarized in Tables 2 and 3. A number of drugs commonly used in the management of chronic heart failure are not recommended during pregnancy.

Angiotensin Converting Enzyme (ACE) inhibitors, Angiotensin Receptor Blockers (ARBs), and renin inhibitors are contraindicated because of fetotoxicity (Cooper et al. 2006; Bullo et al. 2012).

A recent systemic review by Bullo et al. in Hypertension (Bullo et al. 2012) reported on the use of ACE-inhibitors and ARBs from a total of 72 reports. Thirty-seven articles on 118 well-documented cases described the prenatal exposure to ACE-inhibitors and 35 articles on 68 cases described the use of ARBs. Overall, 52 % of the newborns exposed to ACE-inhibitors and 13 % of the newborns exposed to ARBs did not exhibit any complications (p < 0.0001). Neonatal complications were more frequent following exposure to ARBs and included renal failure, oligohydramnions, death, arterial hypertension, intrauterine growth retardation, respiratory distress syndrome, pulmonary hypoplasia, limb defects and persistent patent ductus arteriosus. Fetal adverse effects by both drugs had relevant neonatal and long-term complications. The outcome was poorer following exposure to ARBs versus ACE-inhibitors. The authors rightly concluded that relevant complications are regularly described, indicating that awareness of the deleterious effects of prenatal exposure to drugs inhibiting the renin-angiotensin system should be improved.

For symptomatic relief, and to reduce afterload, hydralazine and nitrates can be used instead of ACE inhibitors/ARBs for afterload reduction. Diuretics should only be used if pulmonary congestion is present since they may decrease blood flow to the placenta. Furosemide and hydrochlorothiazide are most frequently used.

For symptomatic relief, managing tachycardia and improving long-term outcome, beta-blockers can be considered, carefully weighing up the benefit for the mother versus the possible impaired outcome for the fetus and newborn baby. Data on beta-blocker use in pregnancy are limited and conflicting. However, a recently published survey from a Danish birth cohort (Meidahl Petersen et al. 2012), comprising all births in Denmark between 1995 and 2008, explored the effect of beta-blockers on pregnancy outcomes. The authors identified 2,459 pregnancies exposed to beta-blockers. Interestingly, Danish pharmacies are required by law to register all redeemed prescriptions and, therefore, this study included data on exposure to beta-blockers based on information on prescriptions paid for and not only prescribed by the physician. The authors defined being born small for gestational age as having a birth weight below the 10th percentile for the corresponding gestational week. Preterm birth was defined as born before the 37th gestational week. Beta-blocker exposure during pregnancy was found to be associated with increased risk of small for gestational age (SGA) fetuses (adjusted OR 1.97, 95 % CI 1.75–2.23), preterm birth (adjusted OR 2.26, 95 % ci 2.03–2.52) and an increased perinatal mortality (adjusted OR 1.89, 95 % CI 1.25–2.84). The authors found similar risks irrespective of type of beta-blocker used. However, the study has a major limitation in the way that the authors could not adjust for the treatment indication and severity of the maternal disease, nor were they able to rule out confounding factors. Maternal disease could also possibly explain the findings.