Peripartum Cardiomyopathy

Yogi PR

Hasna Medika Cardiovascular Hospital

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Outline
1. Epidemiology
2. Definition
3. Pathophysiology
4. Symptoms and signs
5. Management
6. Prognosis

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 Epidemiology

• The incidence in United States ranges from ≈1 in 1000 to 4000 live births
• Africa and Asia suggest an incidence of ≈1 in 1000 live births
• In northern Nigeria, the incidence of PPCM has been reported as high as 1 in
100 live births

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Definition of peripartum cardiomyopathy

European working group (2010):

‘Peripartum cardiomyopathy (PPCM) is an idiopathic

cardiomyopathy presenting with HF secondary to left
ventricular (LV) systolic dysfunction towards the end of
pregnancy or within 5 months after delivery, where no
other cause of HF is found.

It is a diagnosis of exclusion. The LV may not be dilated but

the ejection fraction (EF) is nearly always reduced below
45%

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 Pathophysiology 5

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Vasculo-hormonal hypothesis of the pathophysiology of peripartum cardiomyopathy

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Risk Factors for the Development of PPCM

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 First occurrence: diagnose peripartum cardiomyopathy

Elkayam U, J Am Coll Cardiol

2011

Presents like decompensated heart failure: dyspnea, peripheral edema

Difficult diagnosis because:

- Symptoms unspecific toward the end of pregnancy and early postpartum
- Cardiologist often not in first line

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Probability score of PPCM proposed by Fett and colleagues
Symptom/Sign 0 point 1 point 2 points
Dyspnea None When climb> 8 steps Walking

Orthopnea None Elevate head only Elevated boy>45°

Unexplained cough None Night-time Day and night
Pitting edema None Below knee Above knee
Weight gain 9th month <1Kg/week 1-2 Kg/week >2 Kg/week
Palpitations None Night-time Day and night

0-2: low risk, continue observation

3-4 mild risk, considering blood BNP
5 or >: high risk, blood BNP and echo

Fett J, Crit Pathways in Cardiol 2010

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First occurrence: diagnose peripartum cardiomyopathy
BNP
ECG

Echo

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Manage Acute Peripartum Cardiomyopathy
-Inotropic agents (dobutamine)
depending on hemodynamic parameters
-Diuretics (furosemide)
-Betablockers
-Use of ACE-I or ARB strictly forbidden
-Vasodilators if SBP>110 (Nitrates,
hydralazyne)
-LMWH if LVEF <35%

- Plan and discuss modality of delivery

(obst/anesth/cardiol)

- Inotropic agents if needed

LVEF < 25%, - Diuretics
transfer to intensive care unit - Initiate betablockers and ACE-I
- Anticoagulation recommended

LVEF > - Beta blockers, ACE-I, diuretics

35%

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Clinical profiles of patients with acute heart failure

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Management of acute heart failure during pregnancy

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Management of acute heart failure during/after pregnancy

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 2016 ESC Guideline
Therapeutic algorithm for HFrEF

. Ponikowski et al. Eur Heart J 2016; 37(27): 2129-2200

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 2016 ESC Guideline
Therapeutic algorithm for HFrEF

Updated : Updated :
Recommendation Recommendation
Class I B Class II A

. Ponikowski et al. Eur Heart J 2016; 37(27): 2129-2200

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 Prognosis
• 50-60% patients show complete or near complete recovery
within the first 6 months postpartum

• High risk period with mortality of 25-50% in the first 3

months postpartum

• Patients with persistent cardiomegaly at 6 months have a

reported mortality of 85% at 5 years

• Subsequent pregnancies are often associated with relapses

and high risk for maternal morbidity and mortality

• should be discouraged in women with PPCM who have

persistent cardiac dysfunction.

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 Take home messages
- Multidisciplinary management in a specialist center

- Consider each case as a very high risk patient

- Management driven on a case-by-case basis

- Remember you’re in charge of 2 lives and the fate of a family

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Simposium Kegawatdaruratan pada layanan primer
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Thank you

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