Cardiac disease in pregnancy and peripartum cardiomyopathy

Cardiac disease in pregnancy Microchapters
Home
Overview
Pathophysiology
Epidemiology and Demographics
Risk Factors
Diagnosis
History and Symptoms
Physical Examination
Electrocardiogram
Exercise Testing
Radiation Exposure
Chest X Ray
Echocardiography
MRI
CT
Catheterization: Pulmonary artery catheterization Cardiac catheterization Cardiac Ablation
Treatment
Cardiovascular Drugs in Pregnancy
Labor and delivery
Resuscitation in Late Pregnancy
Contraindications to pregnancy
Special Scenarios: I. Pre-existing Cardiac Disease: Congenital Heart Disease Repaired Congenital Heart Disease Pulmonary Hypertension Rheumatic Heart Disease Connective Tissue Disorders II. Valvular Heart Disease: Mitral Stenosis Mitral Regurgitation Aortic Insufficiency Aortic Stenosis Mechanical Prosthetic Valves Tissue Prosthetic Valves III. Cardiomyopathy: Dilated Cardiomyopathy Hypertrophic Cardiomyopathy Peripartum Cardiomyopathy IV. Cardiac diseases that may develop During Pregnancy: Arrhythmias Acute Myocardial Infarction Hypertension
Cardiac disease in pregnancy and peripartum cardiomyopathy On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Cardiac disease in pregnancy and peripartum cardiomyopathy All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Cardiac disease in pregnancy and peripartum cardiomyopathy
CDC on Cardiac disease in pregnancy and peripartum cardiomyopathy
Cardiac disease in pregnancy and peripartum cardiomyopathy in the news
Blogs on Cardiac disease in pregnancy and peripartum cardiomyopathy
Directions to Hospitals Treating Cardiac disease in pregnancy
Risk calculators and risk factors for Cardiac disease in pregnancy and peripartum cardiomyopathy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Anjan K. Chakrabarti, M.D. [2]

Synonyms and Keywords: PPCM; PPCMP

Overview

Peripartum cardiomyopathy (PPCM) is a form of dilated cardiomyopathy that is defined as a deterioration in cardiac function presenting between the last month of gestation and up to six months post-partum. The etiology of postpartum cardiomyopathy is unknown. Reported prevalence of postpartum cardiomyopathy in United States is estimated to be 1 case per 1300-15,000 live births. Treatment for the disease is similar to treatment for congestive heart failure. Delivery is the recommeded overall treatment to decrease the volume load, improve ventricular function and simplify the medical management of these patients.

Definition

Peripartum cardiomyopathy is defined as:

• Heart failure within last month of pregnancy or five months postpartum
• Absence of prior heart disease
• No determinable cause
• Strict echocardiographic indication of left ventricular dysfunction:

• Ejection fraction <45% and/or
• Fractional shortening <30%
• End-diastolic dimension >2.7 cm/m2 BSA (body surface area)

Pathophysiology

The etiology of postpartum cardiomyopathy is largely unknown. It has been postulated that a defective antioxidant mechanism may contribute. There are elevated levels of cathepsin D and an increase in total prolactin and angiostatic 16kDa prolactin. These molecules promote:

• Apoptosis
• Inhibit endothelial cell proliferation
• Increase vasoconstriction
• Impair myocyte function

The potential role of prolactin forms the molecular basis of treatment with bromocriptine.

As with other forms of dilated cardiomyopathy, PPCM involves decrease of the left ventricular ejection fraction with associated congestive heart failure and increased risk of atrial and ventricular arrhythmias and even sudden cardiac death.

Differentiating Peripartum Cardiomyopathy from Other Diseases

• Accelerated HTN
• Infection/sepsis
• Diastolic dysfunction
• High output state of pregnancy

Epidemiology and Demographics

• Estimates of incidence 1/1,300-15,000.

Risk Factors

PPCM is more common among women with:

• Prior PPCM
• Multiple pregnancies
• African decent, Haitian descent
• History of toxemia
• Long-term tocolytic use
• Age >30
• Twin Pregnancy

Natural History, Complications and Prognosis

• Some patients will have a relapse of PPCM after a partial or full recovery.
• The course of peripartum CMP is variable.
• PPCM is a leading cause of pregnancy related death in the United States.
• Mortality 25-50% (half deaths in first 3 months).
• 50% improve within 6 months.
• 20% to 40% of patients normalize their LVEF.
• If the LVEF remains poor at 6 months, then mortality is increased.
• PPCM is a risk factor for recurrence with subsequent pregnancies.
• Favorable outcomes with cardiac transplantation.

Diagnosis

History and Symptoms

Signs and symptoms are similar to those of normal pregnancy

Treatment

Medical Therapy

• Delivery is the recommeded overall treatment to decrease the volume load, improve ventricular function and simplify the medical management of these patients.

Pharmacotherapy

Pharmacotherapy should be discontinued or tapered gradually based upon repeated echocardiographic analyses. Some patients will have a relapse of PPCM after a partial or full recovery.

• Bromocriptine blocks release of prolactin (see pathophysiology regarding role of prolactin). This therapy has been shown to increase the left ventricular ejection fraction (LVEF) versus standard treatment. As a side effect, this drug will inhibit lactation.
• Digoxin and diuretics are pregnancy category Class C agents and can be used if the benefits outweigh the risks.
• ACE inhibitors absolutely contraindicated prepartum (hydralazine drug of choice).
• Anticoagulation recommended (heparin prepartum and coumadin postpartum) if the left ventricular ejection fraction (LVEF) is <35%.

Surgery

• Ventricular assist device or cardiac transplantation can be performed in patients with severe refractory congestive heart failure.

References

Template:WikiDoc Sources CME Category::Cardiology