POTD: Peri Partum Cardiomyopathy

>> Definition:

  • Development of HF toward the end of pregnancy (last month) or within 5 months following delivery

  • LV systolic dysfunction with an LVEF < 45%

>> High incidence of PPCM in Haitian (1:300) and Nigerian (1:100) women

>> High incidence in Nigeria may be related to a local custom of eating Kanwa, a dry lake salt for 40 days after delivery.

>> It has been suggested that the development of PPCM in these patients may be related in part to hypervolemia and hypertension.

>> Risk Factors:

  • Age greater than 30 years

  • African descent

  • Multiple gestation pregnancy

  • Hx of preeclampsia, eclampsia, or postpartum hypertension

  • Maternal cocaine abuse

  • Long-term (>4 weeks) oral tocolytic therapy with β-adrenergic agonists such as Terbutaline

>> Management Considerations:

  • Women with HF during pregnancy should be treated similarly to other patients with HF. 

  • Diuretics: Both HCTZ and Furosemide are safe during pregnancy and lactation.

  • β blockers: Although safe during pregnancy, β1-selective blockers are preferred over nonselective β-blockers to avoid anti-tocolytic action induced by β2-receptor blockade.

  • ACE-I/ARB: Improve survival but are contraindicated in pregnancy.

    • Also, since they are secreted in breast milk, breastfeeding must be stopped before starting therapy.

  • In the setting of atrial fibrillation (most common arrhythmia in patients with PPCM):

    • Rhythm control (all safe during pregnancy): Digoxin, Procainamide, Quinidine.

    • Refractory atrial fibrillation requires placement of permanent pacemakers and implantable cardioverter-defibrillators.

    • REMEMBER: Warfarin is teratogenic

>> Prognosis:

  • Death due to PPCM is usually caused by progressive pump failure, sudden death, or thromboembolic events.

  • A subset of patients with PPCM will achieve full recovery of LV function (LVEF > 50%).

    • However, LV dysfunction can re-occur despite initial full recovery.

  • Women with PPCM and persistent LV dysfunction or LVEF ≤ 25% at diagnosis are at high risk for recurrent PPCM.

    • The recommendation in this case is to avoid future pregnancies.

  • Since up to 20 to 60% of women with PPCM have complete recovery of LVEF by 6 months to 5 years, ICD placement should be deferred at least 3 months following presentation.

  • Patients with PPCM are at high risk for thrombus formation and thromboembolism due to both the hypercoagulable state of pregnancy and stasis of blood due to severe LV dysfunction.

    • Still, there is no consensus on prophylactic AC.

      • General recommendation to start AC for EF < 30% or in setting of atrial fibrillation.

  • Notes regarding contraception:

    • Estrogen-Progestin contraceptives (e.g., pills, patch, vaginal ring) may increase fluid retention, which may worsen HF.

    • In general, Estrogen-Progestin contraceptives should be avoided, particularly early after diagnosis and in women with persistent LV dysfunction due to increased risk of thromboembolism.


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