Recommendation 142: We recommend that pregnant women (or those in the peripartum period) with acute HF should be managed according to the CCS guidelines for acute HF and should be referred to a tertiary centre with expertise in advanced HF management, including mechanical circulatory support and cardiac transplantation (Strong Recommendation, Low Quality Evidence).

Recommendation 143: We recommend that natriuretic peptides be used for diagnostic and prognostic purposes in peripartum cardiomyopathy (Strong Recommendation, Low Quality Evidence).

Recommendation 144: We recommend that bromocriptine not be used routinely for peripartum cardiomyopathy (Strong Recommendation, Low Quality Evidence).

Values and preferences: Adequately-powered and appropriately designed RCTs have not been completed. The safety of bromocriptine is not well established.

Recommendation 145: We recommend that echocardiography be performed in women with worsening or suspected new-onset HF during pregnancy (Strong Recommendation, Low Quality Evidence).

Recommendation 146: We recommend pre-pregnancy counselling in all women with a known history of heart failure or peripartum cardiomyopathy (Strong Recommendation, Low Quality Evidence).

Recommendation 147: We recommend preconception genetic counselling in women with inheritable cardiac diseases that can affect cardiac function, including inheritable cardiomyopathies (Strong Recommendation, Low Quality Evidence).

Recommendation 148: We recommend maternal risk assessment and frequency of expert follow-up should be determined using the modified World Health Organization (WHO) risk classification (Strong Recommendation, Low Quality Evidence).

Recommendation 149: We recommend that decisions regarding timing and mode of delivery should be based on obstetrical factors (Strong Recommendation, Low Quality Evidence).

Values and preferences: Caesarean deliveries are not routinely necessary and may additional risk to patients with heart failure. Delivery before term for cardiac decompensation is rarely required.

Practical tip:

Vaginal delivery is preferred in women with stable cardiac conditions.

Recommendation 150: We recommend that patients with PPCM who do not recover normal left ventricular function should be advised against future pregnancies due to the high risk of worsening HF and death (Strong Recommendation, Moderate Quality Evidence).

Recommendation 151: We recommend that patients with PPCM who recover normal left ventricular function should be advised regarding the potential for recurrent left ventricular dysfunction in subsequent pregnancies (Strong Recommendation, Moderate Quality Evidence).

Practical tip:
The risk of thromboembolism associated with PPCM is increased due to the hypercoagulable state of pregnancy, and is highest during the first six weeks postpartum.

Recommendation 152: We recommend that several commonly used cardiac medications should be avoided due to teratogenic effects during pregnancy and with caution during lactation (Strong Recommendation, Moderate Quality Evidence).

• Women with HF during pregnancy should be closely followed and monitored at the time of delivery and the early postpartum period.
• Echocardiography is the preferred imaging modality for heart failure during pregnancy. Post- partum imaging can include cardiac MRI for more accurate detection of changes in cardiac function and higher sensitivity for the detection of thrombus.