Peripartum cardiomyopathy: risk factors and predictors of outcome

PURPOSE OF REVIEW

Peripartum cardiomyopathy (PPCM) contributes significantly to maternal morbidity and mortality worldwide. In this review, we describe the present-day epidemiology and current understanding of the pathogenesis of PPCM. We provide an updated approach to diagnosis and management of PPCM, and discuss risk factors and predictors of outcome.

RECENT FINDINGS

The highest incidences of PPCM have been reported in African, Asian, and Caribbean populations. Contemporary literature supports a 'two-hit' hypothesis, whereby the 'first hit' implies a predisposition, and the 'second hit' refers to an imbalanced peripartal hormonal milieu that results in cardiomyopathy. Whereas a half of patients will have left ventricular (LV) recovery, a tenth do not survive. Clinical findings and special investigations (ECG, echocardiography, cardiac MRI, biomarkers) can be used for risk stratification. Frequent prescription of guideline-directed medical therapy is associated with improved outcomes.

SUMMARY

Despite advances in elucidating the pathogenesis of PPCM, it remains unclear why only certain women develop the disease. Moreover, even with better diagnostic work-up and management, it remains unknown why some patients with PPCM have persistent LV dysfunction or die. Future research should be aimed at better understanding of the mechanisms of disease and finding new therapies that could improve survival and LV recovery.

Peripartum Cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a form of heart failure that occurs toward the end of pregnancy or in the months following pregnancy and is marked by left ventricular systolic dysfunction. The cause of PPCM remains unknown and there is no diagnostic test specific to PPCM. Outcomes vary and include complete left ventricular recovery, persistent cardiac dysfunction, transplant, and death. Numerous advances have been made in understanding this disease, but many knowledge gaps remain. This article reviews recent data and recommendations for clinical practice in addition to highlighting the multiple knowledge gaps related to PPCM that warrant further investigation.

Peripartum cardiomyopathy

Peripartum cardiomyopathy is now increasingly recognized as a cause of heart failure in the later months of pregnancy and early postpartum period. Clinical diagnosis may be challenging as it closely resembles several common medical and obstetric complications. Complex pathogenesis, unpredictable onset, staggered recovery, and unanticipated fetomaternal risks pose unique challenge to clinicians. Prevalence seems to vary with race, geographic location, and diagnostic criteria. The presence of multiple risk factors substantially elevates the risk of PPCM. Transthoracic echocardiographic examination can exclude the majority of the mimickers. Symptomatic presentation is initially limited to, varying grades of low cardiac output syndrome. Rarely, PPCM begins with decompensated heart failure and cardiovascular collapse. Guideline-directed medical therapy involves graded initiation and titration of heart failure medications while ensuring the fetal and neonatal safety. Anesthetic and obstetric management should be individualized to improve fetomaternal outcomes. However, emergent cesarean delivery may be required in women with decompensated heart failure and cardiovascular collapse. An early institution of mechanical circulatory support has shown to improve outcome. Bromocriptine and other experimental drugs designed to target pathogenic pathway have yielded mixed results. A further change in approach to management requires a comprehensive understanding of pathophysiology and fetomaternal safety profiles of heart failure medications.

Peripartum cardiomyopathy: An analysis of clinical profiles and outcomes from a tertiary care centre in southern India

Peripartum cardiomyopathy is a syndrome of maternal heart failure with decreased left ventricular ejection fraction affecting maternal and fetal well-being. We analysed clinical profiles and outcomes in women with peripartum cardiomyopathy enrolled retrospectively from a tertiary care centre in southern India (1 January 2008-31 December 2014). The incidence of peripartum cardiomyopathy was one case per 1541 live births. Fifty-four women with a mean age of 25.5 years and mean gestational age of 35.4 weeks were recruited; 35 were primigravidae. Maternal and fetal deaths occurred in 9.3% and 24.1% of subjects, respectively. Mild-to-moderate maternal anaemia (80-110 g/L) was associated with fetal mortality (p = 0.02). Reduced left ventricular ejection fraction (<30%, p = 0.04) and cardiogenic shock (p = 0.01) were significantly associated with adverse maternal outcomes. Forty per cent of women were followed up after 24.2 ± 17.7 months, and in these women a significant increase in left ventricular ejection fraction was seen (mean 16.4%, p < 0.01); all were asymptomatic. Peripartum cardiomyopathy with poor left ventricular ejection fraction and shock is associated with adverse maternal outcomes, while non-severe maternal anaemia predisposes to adverse fetal outcomes. Significant left ventricular ejection fraction recovery occurred on follow-up.

Peripartum Cardiomyopathy

Peripartum cardiomyopathy is a potentially life-threatening pregnancy-associated disease that typically arises in the peripartum period and is marked by left ventricular dysfunction and heart failure. The disease is relatively uncommon, but its incidence is rising. Women often recover cardiac function, but long-lasting morbidity and mortality are not infrequent. Management of peripartum cardiomyopathy is largely limited to the same neurohormonal antagonists used in other forms of cardiomyopathy, and no proven disease-specific therapies exist yet. Research in the past decade has suggested that peripartum cardiomyopathy is caused by vascular dysfunction, triggered by late-gestational maternal hormones. Most recently, information has also indicated that many cases of peripartum cardiomyopathy have genetic underpinnings. We review here the known epidemiology, clinical presentation, and management of peripartum cardiomyopathy, as well as the current knowledge of the pathophysiology of the disease.

Peripartum cardiomyopathy: ten year experience at a tertiary care hospital in Pakistan

BACKGROUND

There is very little literature regarding peripartum cardiomyopathy from the Asian countries. We conducted this study to determine demographic details, clinical presentations, complications and recovery of left ventricular (LV) systolic function in peripartum cardiomyopathy (PPCMP) patients of Pakistani origin.

METHOD

A ten year retrospective case series of PPCMP was conducted at the Aga Khan University Hospital. Patients were also followed up for six months after presentation, with special regard to improvement in the LV function.

RESULTS

Total 45 patients were included, 25 (55.5%) primigravida and 8 (17.7%) gravida 2 and the remaining 12 (26.6%) were multigravida. Fourteen patients (31.1%) presented during pregnancy and 31 (68.8%) after delivery. All patients presented with CHF and three (6.6%) were complicated with ventricular tachycardia (VT) at presentation. LV systolic dysfunction was present in 39 (86.66%) patients and RV dysfunction in 15 (33.3%) patients. Two patients had LV clot and thromboembolic stroke occurred in another 4 patients. All patients received standard treatment except three patients who had asthma and could not be given beta blockers. Echocardiogram was repeated after 6 month and in 32 (71.1%) patients LV functions recovered to normal. RV function improved in all except 2 (4.4%) patients. All patients were discharged in stable condition.

CONCLUSION

Significant numbers of PPCMP patients, who had severe LV dysfunction at presentation recovered their LV functions at six month follow up.

Pregnancy with dilated and peripartum cardiomyopathy: maternal and fetal outcome

BACKGROUND

A retrospective review of the records of all the patients of dilated cardiomyopathy (DCM) with pregnancy at PGIMER, Chandigarh, India, in order to find out maternal and fetal outcome.

MATERIALS AND METHODS

We did a retrospective analysis of records of diagnosed cases of DCM from 1994 to 2010. There were records of 38 patients who had DCM with pregnancy. Detailed history was followed by systemic examination, routine investigations and echocardiography. Multidisciplinary care was given to these women by obstetrician, cardiologist, anesthetist and neonatologist. Pharmacotherapy consisted to diuretics, alpha and beta blockers and heparin or low-dose aspirin for thrombo prophylaxis. Elective induction of labor was advised after 37 weeks of gestation subject to favorability of cervix.

RESULTS

Out of 1,472 patients of heart disease during study period, 38 women had DCM. Out of these, 8 (21 %) had idiopathic cardiomyopathy, two had DCM due to thyrotoxicosis and 28 (73.6 %) patients had peripartum cardiomyopathy. Mean gestational age at the time of presentation was 35 weeks. Majority of the patients (19/38) presented with complaints of exertional dyspnoea. Mean LVEF at the time of diagnosis was 32.28 %. There were six (15.8 %) maternal deaths and all of them had global hypokinesia on echocardiography and presented in NYHA class IV. Fetal outcome too depended upon maternal cardiac status. There were eight stillbirths and all the patients who had IUFD belonged to class IV. Twelve patients (40 %) had preterm delivery. Mean birth weight of babies was 2 kg.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a potentially devastating disease that affects women during the last months of pregnancy or the first months after delivery. The aetiology and pathogenesis of this disease remain unclear, but oxidative stress and the generation of a cardiotoxic fragment of prolactin may play key roles. Diagnosing PPCM remains a challenge, as symptoms may mimic those women experience during normal pregnancy and the peripartum period. A high index of suspicion is thus necessary to make the diagnosis. Patients with PPCM have a varied clinical course, as some patients achieve full recovery while others progress to end-stage heart failure and even death. Standard heart failure treatment is indicated, although special provisions are necessary in pregnant and lactating women. Additional research into the pathophysiology of this disease, including possible genetic contributions, may lead to novel treatment strategies that can improve outcomes.