Peripartum cardiomyopathy

Abstract

According to current definition, peripartum cardiomyopathy (PPCM) is a rare disorder in which left ventricular dysfunction and symptoms of heart failure occur in the last month of pregnancy. It has been reported that the incidence of PPCM is 1 in 3,000-4,000 live births. The pathogenesis is poorly understood, however, infectious, immunologic, and nutritional causes have been hypothesized. Clinical presentation includes usual signs and symptoms of heart failure, and unusual presentations such as thromboembolism. Diagnosis is based upon the clinical presentation of congestive heart failure and the objective evidence of left ventricular systolic dysfunction. Early diagnosis and initiation of treatment are essential to optimize pregnancy outcome. Patients with systolic dysfunction during pregnancy are treated similar to patients who are not pregnant. The mainstays of medical therapy are digoxin, loop diuretics, sodium restriction and afterload reducing agents (hydralazine and nitrates). Due to a high risk for venous and arterial thrombosis, anticoagulation with subcutaneous heparin should be instituted. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be avoided during pregnancy because of severe adverse neonatal effects. Effective treatment reduces mortality rates and increases the number of women who fully recover left ventricular systolic function. The prognosis is poor in patients with persistent cardiomyopathy. Subsequent pregnancies are often associated with recurrence of left ventricular systolic dysfunction.

Peripartum cardiomyopathy: an obstetric review

“…Persistent nocturnal dry cough, orthopnea and paroxysmal nocturnal dyspnea are frequently reported. 34 Other non-specific symptoms include dizziness, chest pain, abdominal discomfort and palpitations. Rarely, acute cyanosis, thromboembolic episodes and liver failure have also been reported.…”

Favorable course of peripartum cardiomyopathy (RCD code: VII-III-5C)

“…Aldosterone antagonists, both spironolactone and eplerenon, should be avoided during pregnancy because of the unknown interactions with hormonal pathways. On the other hand, less frequently used hydralazine and long-acting nitrates are valuable replacements for ACEIs and ARBs [13]. Finally, antithrombotic therapy should be considered in patients with seriously depressed LVEF, especially in the setting of atrial fibrillation.…”

Peripartum Cardiomyopathy: A Systematic Review

“…On the basis of several reports series of PPCM, varying genetic pools and diverse environmental factors have been proposed as risk factors in different areas. Although not clearly delineated, there are several suggested risk factors for development and recurrence of PPCM (Bahloul et al, 2009;Demakis et al, 1971;Fett et al, 2005a;Fisher et al, 2008;Murali & Baldisseri, 2005;Moioli et al, 2010;Nkoua et al, 1991;Ntusi & Mayosi, 2009;Pearson et al, 2000;Sliwa 2006aSliwa , 2006b): -African race -appears to be the strongest risk factor, possibly due to a greater incidence of arterial hypertension in this group. Brar et al reported the incidence of PPCM in African-American women to be 2.9-fold higher than in whites, and 7-fold than in Hispanics (Brar et al, 2007).…”

“…The association with left ventricular dysfunction seems to be unique to pregnancy, as the same drugs do not determine similar complications in nonpregnant patients, even at high doses. -certain cultural practices performed during the puerperium which are frequently related with high incidence of PPCM, such as consuming lake salt or rock salt known as "kanwa" (to promote the flow of breast milk), or heating of the body on a clay bed with a fire beneath to keep warm (Moioli et al, 2010;Murali & Baldisseri, 2005); -socio-economic level is discussed as a risk factor, and can be summarized in a stereotyped profile: "poor African female, with malnutrition and multiparity, making strenuous and sustained physical effort during pregnancy" (Bahloul et al, 2009). …”

“…The most common symptoms are dyspnea and fatigue (90%), tachycardia (62%), and peripheral edema (60%) (Elkayam et al, 2005). Other symptoms like persistent nocturnal dry cough, orthopnea, paroxysmal nocturnal dyspnea are frequently reported (Moioli et al, 2010). NYHA class III or IV functional status seem to be the most common initial presentation (Desai et al, 1995).…”