Table 2: Heart failure drug safety profile in pregnancy and lactation

Medication	FDA Pregnancy category	Lactation Safety
Diuretics Bumetanide Furosemide Torsemide Hydrochlorothiazide Metolazone	C C B B B	Unknown Enters breast milk; may suppress lactation Unknown Enters breast milk; not recommended Enters breast milk; not recommended
ACE Inhibitors Captopril Enalapril Lisinopril Ramipril	D D D D	Enters breast milk; not recommended Enters breast milk; not recommended Unknown Unknown
Angiotensin receptor blockers Candesartan Losartan Valsartan	D C (1^st trimester) D (2^nd/3^rd trimester) D	Unknown Unknown Unknown
Beta Blockers Bisoprolol Carvedilol Metoprolol succinate Metoprolol tartrate	C C C C	Unknown Unknown Enters breast milk; use with caution Enters breast milk; use with caution
Aldosterone antagonists Eplerenone Spironolactone	B C	Unknown Enters breast milk; not recommended
Vasodilators Hydralazine Isosorbidedinitrate Isosorbidemononitrate	C C B/C	Enters breast milk; use with caution Unknown Enters breast milk; use with caution
Digoxin	C	Enters breast milk; use with caution
Anticoagulants Enoxaparin Unfractionated heparin Warfarin	B C D (women with mechanical heart valves); X (other indications)	Unknown Does not enter breast milk Does not enter breast milk

Food and Drug Administration (FDA) Pregnancy categories: A: controlled studies in pregnant women fail to demonstrate a risk to the fetus in the first trimester with no evidence of risk in later trimesters. The possibility of fetal harm appears remote. B: No evidence of risk in studies. Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester and there is no evidence of a risk in later trimesters; C: Risk cannot be ruled out. Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal effects or other) and there are no controlled studies in women, or studies in women and animals are not available. Drugs should be given only if the potential benefits justify the potential risk to the fetus; D: Positive evidence of risk. There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (e.g., if the drug is needed in a lifethreatening situation or for a serious disease for which safer drugs cannot be used or are ineffective); X: Contraindicated in pregnancy. Studies in animals or human beings have demonstrated fetal abnormalities or there is evidence of fetal risk based on human experience, or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant. ACE: angiotensin-Converting Enzyme