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13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan

2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)

11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes

Key Takeaways Explain This Topic AI

Hypertension in pregnancy and diabetes mellitus in pregnancy are enumerated topics within the pregnancy blueprint subsection.

Preeclampsia is new hypertension after 20 weeks with proteinuria or end-organ dysfunction, and severe features can occur without proteinuria.

Magnesium sulfate is given for seizure prophylaxis in preeclampsia with severe features and for treatment of eclampsia.

Labetalol, nifedipine and methyldopa are the preferred antihypertensives in pregnancy, and renin-angiotensin blockers are contraindicated.

Low-dose aspirin started in the late first trimester reduces preeclampsia risk in women with high-risk features.

Last updated: August 2026

1. Hypertensive Disorders of Pregnancy

Hypertensive disorders complicate up to 10% of pregnancies and represent a leading cause of maternal and perinatal morbidity and mortality worldwide.

Clinical Spectrum & Diagnostic Criteria

Chronic Hypertension:

Systolic BP >= 140 mmHg and/or Diastolic BP >= 90 mmHg diagnosed prior to pregnancy or before 20 weeks of gestation , or persisting >12 weeks postpartum.

CHAP Trial Benchmark: In pregnant women with mild chronic hypertension, treating to a blood pressure target of <140/90 mmHg (target 110-135/85 mmHg) significantly reduces the risk of preeclampsia, preterm birth, placental abruption, and fetal/neonatal death without impairing fetal growth.

First-line oral agents: Labetalol (100-800 mg PO BID-TID), Extended-Release Nifedipine (30-90 mg PO daily), and Methyldopa (250-1000 mg PO BID-TID).

Gestational Hypertension:

New-onset systolic BP >= 140 mmHg and/or diastolic BP >= 90 mmHg on two occasions at least 4 hours apart developing after 20 weeks of gestation in a previously normotensive woman, without proteinuria or systemic severe features .

Preeclampsia:

New-onset hypertension (SBP >= 140 or DBP >= 90 mmHg after 20 weeks) PLUS Proteinuria :

  • = 300 mg per 24-hour urine collection, OR
  • Urine Protein-to-Creatinine Ratio (UPCR) >= 0.3 mg/mg (30 mg/mmol), OR

Urine dipstick protein >= 2+ (used only if quantitative methods unavailable).

Preeclampsia in the Absence of Proteinuria: Diagnosed when new-onset hypertension after 20 weeks is accompanied by any Severe Feature :

  • Severe Blood Pressure: SBP >= 160 mmHg or DBP >= 110 mmHg on 2 occasions >=15 minutes apart
  • Thrombocytopenia: Platelet count < 100,000 /µL

Impaired Liver Function: Serum transaminases (AST/ALT) > 2x upper limit of normal , or severe persistent right upper quadrant / epigastric pain unresponsive to analgesics

Renal Insufficiency: Serum creatinine > 1.1 mg/dL or a doubling of serum creatinine in the absence of other underlying renal disease

Pulmonary Edema

New-Onset Cerebral or Visual Disturbances: Photopsia, scotomata, cortical blindness, severe persistent throbbing headache unresponsive to acetaminophen

Eclampsia:

Development of new-onset generalized tonic-clonic seizures in a woman with preeclampsia, in the absence of other neurological conditions (epilepsy, intracranial hemorrhage, encephalitis).

HELLP Syndrome:

Severe variant of preeclampsia characterized by:

H emolysis: Microangiopathic hemolytic anemia with schistocytes on peripheral smear, elevated total bilirubin >=1.2 mg/dL, and elevated LDH > 600 U/L

  • E levated L iver enzymes: Serum AST or ALT >= 2x upper limit of normal
  • L ow P latelets: Thrombocytopenia with platelet count < 100,000 /µL
  • Preeclampsia Prevention with Low-Dose Aspirin

Indication: Recommended for women at high risk of preeclampsia (history of preeclampsia, multifetal gestation, chronic hypertension, pregestational type 1 or 2 diabetes, chronic kidney disease, autoimmune disease [SLE, antiphospholipid syndrome]). Also recommended if >=2 moderate risk factors (nulliparity, obesity BMI >30, maternal age >=35, black race, low socioeconomic status).

Regimen: Low-dose Aspirin (81 to 162 mg daily) initiated between 12 and 16 weeks of gestation (and before 28 weeks) and continued daily until delivery.

Acute Management of Severe Preeclampsia & Eclampsia +-----------------------------------------------------------------------------------+

  • | ACUTE MANAGEMENT OF SEVERE PREECLAMPSIA / ECLAMPSIA |
  • +-----------------------------------------------------------------------------------+
  • | 1. SEIZURE PROPHYLAXIS: Intravenous Magnesium Sulfate |
  • | - Loading Dose: 4 to 6 g IV over 15-20 minutes |
  • | - Maintenance Dose: 1 to 2 g/hour continuous IV infusion |
  • | - Duration: Maintain throughout labor and for 24 hours postpartum |
  • | - Monitoring: Patellar reflexes (loss at 9-12 mg/dL), RR (>12/min), |
  • | urine output (>=30 mL/hr; Mg is cleared 100% renally) |
  • | - Toxicity Antidote: IV Calcium Gluconate (1 g IV 10% solution over 5 min) |
  • +-----------------------------------------------------------------------------------+
  • | 2. URGENT ANTIHYPERTENSIVE THERAPY (SBP >=160 or DBP >=110 mmHg >=15 min) |
  • | - IV Labetalol: 20 mg IV initial -> 40 mg at 10 min -> 80 mg q10m (max 300 mg) |
  • | - IV Hydralazine: 5-10 mg IV initial -> 10 mg at 20 min (max 20-30 mg) |
  • | - Oral Nifedipine IR: 10-20 mg PO (repeat in 20-30 min PRN; avoid sublingual) |
  • +-----------------------------------------------------------------------------------+
  • | 3. DEFINITIVE TREATMENT: Planned Delivery |
  • | - >=34 0/7 weeks with severe features: Prompt delivery after stabilization |
  • | - Maternal/fetal instability (eclampsia, HELLP, pulmonary edema, abruption, |
  • | non-reassuring fetal tracing): Immediate delivery at ANY gestational age |
  • | - Without severe features: Planned delivery at 37 0/7 weeks |
  • +-----------------------------------------------------------------------------------+
  • 2. Gestational Diabetes Mellitus (GDM)
  • Pathophysiology & Screening Protocols

During normal pregnancy, placental secretion of diabetogenic hormones—predominantly Human Placental Lactogen (hPL) , progesterone, cortisol, and prolactin—induces physiologic maternal peripheral insulin resistance to facilitate glucose shunting to the developing fetus. Gestational Diabetes Mellitus (GDM) develops when maternal pancreatic beta-cell insulin secretion is insufficient to overcome this pregnancy-induced insulin resistance.

Universal Screening at 24 to 28 Weeks Gestation:

Two-Step Approach (ACOG / Carpenter-Coustan Criteria):

Step 1: 1-hour 50g non-fasting oral Glucose Challenge Test (GCT). If plasma glucose is >= 130 to 140 mg/dL , proceed to Step 2.

Step 2: 3-hour 100g diagnostic oral Glucose Tolerance Test (OGTT) performed after an overnight 8-hour fast. Diagnosis is established if >= 2 values meet or exceed the following cutoffs:

  • Fasting: >= 95 mg/dL (5.3 mmol/L)
  • 1-hour: >= 180 mg/dL (10.0 mmol/L)
  • 2-hour: >= 155 mg/dL (8.6 mmol/L)
  • 3-hour: >= 140 mg/dL (7.8 mmol/L)

One-Step Approach (IADPSG / ADA Criteria): Fasting 2-hour 75g OGTT. Diagnosis is established if >= 1 value is abnormal: Fasting >=92 mg/dL, 1-hour >=180 mg/dL, or 2-hour >=153 mg/dL.

  • Glycemic Targets in Pregnancy
  • Fasting blood glucose: < 95 mg/dL (5.3 mmol/L)
  • 1-hour postprandial blood glucose: < 140 mg/dL (7.8 mmol/L)
  • 2-hour postprandial blood glucose: < 120 mg/dL (6.7 mmol/L)
  • HbA1c target: < 6.0% to 6.5%
  • Stepwise Management of GDM

First-Line Lifestyle & Medical Nutrition Therapy (MNT):

Individualized dietary counseling with controlled carbohydrate distribution (33-40% complex low-glycemic carbohydrates, 20% protein, 40% healthy fats) distributed across 3 meals and 2-3 snacks.

Moderate postprandial physical activity (e.g., 30 minutes of brisk walking daily).

Blood glucose monitoring 4 times daily (fasting and 1- or 2-hour postprandial after each meal).

Pharmacotherapy:

Indicated if >20% of blood glucose values exceed targets on MNT alone over 1 to 2 weeks.

Insulin is the Gold Standard First-Line Medication: Insulin does not cross the placenta and provides precise glycemic titration. Typical starting dose is 0.7-1.0 units/kg/day in divided basal-bolus regimens (e.g., NPH or Detemir basal plus Lispro or Aspart rapid-acting prandial insulin).

Oral Agents (Second-Line):

Metformin: Crosses the placenta freely (fetal levels equal maternal levels). Associated with lower maternal weight gain and lower neonatal hypoglycemia compared to insulin, but has higher treatment failure rates requiring supplemental insulin (~30-40%) and potential long-term childhood metabolic impact (slightly higher childhood BMI).

Glyburide (Sulfonylurea): Crosses the placenta and is associated with increased rates of neonatal hypoglycemia and fetal macrosomia compared to insulin.

Postpartum Screening & Long-Term Risks:

Women with GDM have a 50% to 70% lifetime risk of developing overt Type 2 Diabetes.

All women with GDM must undergo a 2-hour 75g oral glucose tolerance test at 4 to 12 weeks postpartum to screen for persistent diabetes or impaired glucose tolerance.

If postpartum OGTT is normal, repeat glycemic screening every 1 to 3 years indefinitely.

5. Peripartum Cardiomyopathy

Peripartum cardiomyopathy is explicitly enumerated in the pregnancy blueprint subsection, and it is a diagnosis internists are positioned to make because the presenting symptoms are routinely attributed to normal late pregnancy.

Definition: new systolic heart failure with a left ventricular ejection fraction below 45% , developing in the last month of pregnancy or within five months postpartum , in a woman with no previously known structural heart disease and no other identifiable cause.

Why it is missed: dyspnea, orthopnea, fatigue and lower-extremity edema are all features of normal late pregnancy and the early puerperium. The findings that should prompt echocardiography rather than reassurance are paroxysmal nocturnal dyspnea, an S3 gallop, elevated jugular venous pressure, resting tachycardia, hypoxemia, and symptoms that worsen rather than improve after delivery .

Risk factors: advanced maternal age, multiparity, multiple gestation, preeclampsia and hypertensive disorders of pregnancy , African ancestry, and prolonged tocolytic therapy.

Evaluation: echocardiography is the key test. Natriuretic peptides are elevated and, although interpretation in pregnancy requires care, a normal natriuretic peptide level makes the diagnosis unlikely . Exclude pulmonary embolism, amniotic fluid embolism, severe preeclampsia with pulmonary edema, and pre-existing cardiomyopathy unmasked by the hemodynamic load of pregnancy.

Management differs before and after delivery:

Antepartum Postpartum

ACE inhibitors / ARBs / ARNI Contraindicated (fetotoxic) Indicated ; several ACE inhibitors are compatible with breastfeeding

  • Beta-blockers Beta-1 selective preferred Indicated
  • Mineralocorticoid antagonists Generally avoided Indicated
  • SGLT2 inhibitors Not used Used per heart failure guidelines once not breastfeeding
  • Diuretics Used cautiously for congestion Used for congestion

Anticoagulation Considered with very low ejection fraction, given the prothrombotic state Considered with very low ejection fraction

Prognosis and counseling: roughly half of women recover ventricular function, most within six months, and recovery is more likely when the initial ejection fraction is higher. Subsequent pregnancy carries a substantial risk of relapse and of death , and that risk is markedly higher in women whose ejection fraction has not normalized. Pre-conception counseling with cardiology and maternal-fetal medicine is essential, and effective contraception should be provided in the interim. Guideline-directed therapy should not be stopped as soon as the ejection fraction normalizes , since withdrawal is associated with relapse.