Although treatment of heart failure should follow the same principles as in the non-pregnant state,
drug therapy has to be modified. Cardioselective beta blockers (bisoprolol and metoprolol) can be used
with appropriate monitoring of foetal growth. Hydralazine and oral nitrates may be used as vasodilator
agents instead of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers
(ARB). The latter are not recommended because of foetal toxicity, but they may be used in individual
cases following specialist advice if the maternal benefits are considered to outweigh the foetal risks.
Similarly, loop diuretics should be used instead of aldosterone antagonists unless the maternal benefits
of spironolactone outweigh the foetal risk.