Peripartum Cardiomyopathy

Peripartum cardiomyopathy (PPCM) or postpartum cardiomyopathy is an uncommon form of heart failure which occurs during the last month of pregnancy or up to five months of delivery. Cardiomyopathy literally means heart muscle disease. Here, the heart chambers enlarge causing muscle weakness leading to a decrease in the percentage of blood ejected from the left ventricle with each contraction. This leads to less blood flow and decreased blood supply to all organs.




PPCM is diagnosed when the following three criteria are met:

  1. Heart failure develops in the last month of pregnancy or within 5 months of delivery.
  2. Heart pumping is reduced with an ejection fraction (LVEF) less than 45%.
  3. No other cause for heart failure with reduced EF can be found.

It can occur in women above 30 years, African American women, multiparous women, women with preeclampsia or hypertension and obesity, and those who smoke or are malnourished. Women who develop PPCM are at high risk of developing the same condition with future pregnancies. Majority (71%) recover by 6 months post partum. However, persistent cardiomyopathy may be seen in 13-15% women.

  1. Heart failure develops in the last month of pregnancy or within 5 months of delivery.
  2. Heart pumping is reduced with an ejection fraction (LVEF) less than 45%.
  3. No other cause for heart failure with reduced EF can be found.

Symptoms :

Breathlessness especially while lying down or on exertion, dizziness and decreased exercise capacity often are normal symptoms in pregnant women. New or rapid onset of the following symptoms requires prompt evaluation:

  • Excessive Fatigue
  • Feeling of heart racing or skipping beats (palpitations)
  • Increased night-time urination (nocturia)
  • Shortness of breath with activity and when lying flat
  • Swelling of the ankles
  • Swollen neck veins
  • Excessive cough

During a physical examination, the doctor may find signs of fluid in the lungs and lower limbs. A stethoscope will be used to listen for lung crackles, a rapid heart rate, or abnormal heart sounds. An echocardiogram can detect the cardiomyopathy by showing the diminished functioning of the heart.

Causes:

The underlying cause is unclear. Heart biopsies in some women have shown inflammation in the heart muscle due to previous viral illness or abnormal immune response. Other potential causes include genetics, poor nutrition, small-vessel disease, coronary artery spasm and defective antioxidants.

Risk factors include:

  • Multiple pregnancies
  • Poor nutrition
  • Obesity
  • History of cardiac disorders
  • Smoking
  • Alcohol

Diagnosis:

ECG and ECHO (Echocardiogram) is done to assess left ventricular function, valve structure, chamber size, and wall motion. In PPCM, ECHO shows decrease in the heart pumping (LVEF <45%).

If necessary, Chest X-ray (CXR) is done with abdominal shielding to reduce the fetal radiation exposure. CXR may reveal patchy infiltrates in the lower lung fields with vascular redistribution with cardiomegaly with pleural effusion.

Laboratory tests to assess kidney, liver and thyroid function, markers of cardiac injury and stress and complete blood count to look for anemia or evidence of infection are also done. Rarely, cardiac biopsy is advised to determine the underlying cause.

Treatment:

Treatment is focussed on improving the heart function and to keep extra fluid from collecting in the lungs.

Medications for management of PPCM are similar to those used for Heart Failure in general (link to HF webpage, treatment section), except that drugs affecting the baby in the mother’s womb or those contraindicated in breastfeeding are avoided as per the situation.

Avoidance of excessive salt and restriction of fluid intake are generally advised. Smoking and alcohol are inadvisble, as these may make the symptoms worse. Thyroid disease and coexisting anemia are treated diligently.

With good adherence to treatment, many women recover normal heart function or stabilize on medications. Some patients progress to severe heart failure requiring mechanical support or heart transplantation.

CONDITIONS & TREATMENTS