Cardiac disease in pregnancy and peripartum cardiomyopathy
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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, . 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 Disorders
- Accelerated HTN
- Infection/sepsis
- Diastolic dysfunction
- High output state of pregnancy
Epidemiology and Demographics
- Estimates of incidence 1/1300-15000. Previous studies likely overestimated
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
Diagnosis
History and Symptoms
Signs and symptoms are similar to those of normal pregnancy
Hemodynamic Findings
| Chamber | Normal Pregnancy | Peripartum cardiomyopathy |
|---|---|---|
| Right atrium | 2 | 11 (2-34) |
| Pulmonary artery | 11 | 39 (18-62) |
| Pulmonary capillary wedge pressure | 6 | 18 (5-32) |
| Cardiac output (L/min) | 7 | 6 (5-9) |
| Heart rate | 83 | 104 (76-142) |
Treatment
- Delivery is the recommeded overall treatment to decrease the volume load, improve ventricular function and simplify the medical management of these patients.
Pharmacotherapy:
- Bromocriptine
- Digoxin and diuretics are Class C recommendation.
- ACE inhibitors absolutely contraindicated prepartum (hydralazine drug of choice).
- Anticoagulation recommended (heparin prepartum and coumadin postpartum).
Prognosis
- 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.