Managing Cardiovascular Medications in Pregnancy, Lactation: "No Data" Does Not Always Mean "Unsafe"

This panel, part of an American College of Cardiology (ACC) initiative, features moderator Jessie Dunne, PharmD, BCPS, BCCP, FACC, a clinical pharmacist at Oregon Health & Science University, as well as panelists:

• Kayle Shapero, MD, PhD, a cardiologist at Brown University Health and assistant professor of medicine at Brown University's Warren Alpert Medical School;
• and Ashley Schenk, PharmD, AACC, BCCP, BCPS, a cardiology clinical pharmacist at University of Kentucky (UK) HealthCare and an adjunct assistant professor at the UK College of Pharmacy.

The panelists say that medical and pharmacy training give limited attention to medication safety in pregnancy and lactation. Often, clinicians learn which drugs are clearly teratogenic, but they get little guidance on the large “gray area” of choosing the next safest option.

They identify a common misconception: the belief that a drug with no data must be harmful. Shapero explains that patients often arrive at clinic pregnant after stopping every medication, sometimes because of something they read online. For some conditions, stopping treatment can carry far more risk to the patient and fetus than continuing it. To guide decisions, the panelists use electronic health record alerts, LactMed, DynaMedex, and Briggs Drugs in Pregnancy and Lactation as resources. They also check PubMed, because case reports can take time to reach tertiary references. Schenk adds that the FDA has replaced its A, B, C, D, and X pregnancy letter categories with summaries of the available human and animal data.

The panel names several high-risk areas: heart failure, where many guideline-directed medications either lack data or are likely teratogenic; hypertension; anticoagulation; arrhythmias; and pulmonary hypertension, where clinicians often counsel patients to avoid pregnancy. Shapero says psychiatric medications also need attention, because stopping them can destabilize patients. The panelists stress that the medication regimen should be reviewed prior to pregnancy, so the health care team can decide what medications to keep, what to replace, and when to refer the patient to specialized maternal-fetal care.