Background: Cardiomyopathy during pregnancy is associated with significant maternal and fetal morbidity and mortality. Management remains challenging because many guideline-directed heart failure therapies are contraindicated during pregnancy due to concerns regarding fetal safety. Eplerenone, a selective mineralocorticoid receptor antagonist, is an established therapy for heart failure with reduced ejection fraction; however, evidence supporting its use during pregnancy remains limited.
Case Presentation: We report the case of a 30-year-old primigravida woman with severe pre-existing cardiomyopathy, diabetes mellitus, severe obesity, diabetic nephropathy, obstructive sleep apnoea, and previous pulmonary embolism. Early pregnancy echocardiography demonstrated severe left ventricular systolic dysfunction with a left ventricular ejection fraction (LVEF) of 25–30%. Despite multidisciplinary management and optimisation of beta-blocker therapy, serial echocardiography showed persistent severe ventricular dysfunction. Following multidisciplinary review and extensive counselling regarding the limited available evidence, eplerenone was introduced at 21 weeks' gestation.
Results: Treatment was well tolerated and was associated with significant symptomatic improvement and a reduction in BNP levels, although no substantial improvement in LVEF was observed. The pregnancy was complicated by progressive heart failure symptoms and worsening right ventricular dysfunction, necessitating preterm Caesarean delivery at 28+6 weeks' gestation. A healthy male infant was delivered. Postpartum, the patient experienced mild decompensated heart failure that responded to medical therapy, with subsequent clinical improvement.
Conclusion: This case highlights the challenges of managing severe cardiomyopathy during pregnancy and adds to the limited literature regarding eplerenone use in this setting. Eplerenone may represent a therapeutic option in carefully selected pregnancies when conventional heart failure therapies are contraindicated.