Cardiac disease in pregnancy and peripartum cardiomyopathy

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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
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Anjan K. Chakrabarti, M.D. [3]

Synonyms and Keywords: PPCM;

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 five months post-partum.

The etiology of postpartum cardiomyopathy is unknown. 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.

In the US the prevalence is estimated to be 1 case per 1300-15,000 live births. The incidence of peripartum cardiomyopathy is increased in women over the age of 30, in twin pregnancies, in multiparous women, in women with gestational hypertension, those who have received tocolytic therapy, and in african americans.

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)

Common Mimickers

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

Demographics

• Estimates of incidence 1/1300-15000
• Previous studies likely overestimated
• More common in women with:

• Multiple pregnancies
• African decent
• h/o toxemia
• Long-term tocolytic use
• Age>30
• Twin Pregnancy

• Etiology remains unknown
• Signs and sxs similar to those of nl pregnancy

Hemodynamic Findings

Chamber	Normal Pregnancy	Peripartum cardiomyopathy
RA	2	11 (2-34)
PA	11	39 (18-62)
PCW	6	18 (5-32)
CO (L/min)	7	6 (5-9)
HR	83	104 (76-142)

Treatment of Peripartum Cardiomyopathy

• Digoxin and diuretics are Class C
• ACE inhibitors absolutely contraindicated prepartum (hydralazine drug of choice)
• Anticoagulation recommended (Heparin prepartum and coumadin postpartum)

Outcome of Peripartum Cardiomyopathy

• Mortality 25-50% (half deaths in first 3 months)
• Remainder stable/recover within 6 months
• Can recur with subsequent pregnancies
• Favorable outcomes with cardiac transplantation

References

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