Peripartum Cardiomyopathy - Summary

1. Definition

 • Towards the end of pregnancy to 5 months postpartum 

 • Usually LVEF <45% with or without LV dilation

 • Idiopathic LV dysfunction → exclude other causes*

2. Differential Diagnosis

 • Pre-existing cardiomyopathy (e.g., familial or dilated)

 • Valvular heart disease

 • Congenital heart disease

 • Hypertensive heart disease

 • Myocardial infarction

 • Stress cardiomyopathy

 • Pulmonary embolus

3. Etiology

 • Actual etiology remains unknown

 • Final pathway likely an imbalance of angiogenic factors + oxidative stress

    - Proposed Mechanism: Dysregulation of VEGF (Pro-Angiogenic) through ↑ sFLT1 levels (levels ↑ in pre-eclampsia)

    - Proposed Mechanism: Altered prolactin processing with ↑ cleavage into a pro-angiogenic fragment

 • Other: Myocarditis? Genetic predisposition (TTN gene) ? Hemodynamic stressors of pregnancy

4. Risk Factors and Worse Prognostic Markers

 • Risk Factors: African ancestry, pre-eclampsia, hypertension, multiple pregnancy, maternal age > 30 years, cocaine use

 • Worse Prognosis: LVEF < 30%, LVEDd > 6.0 cm, LV thrombus, RV systolic dysfunction, Obesity, African ancestry, LGE on MRI

5. Clinical

 • Under-recognized: sx overlap with normal pregnancy

 • May have typical HF sx: dyspnea on exertion, orthopnea, PND, LE edema

 • Minority of Pts: cardiogenic shock and severe arrhythmias

6. Management during Pregnancy

 • Avoid ARB/ACE-I/ARNI/MRA

 • Avoid Warfarin and DOAC

 • Planning for delivery mode and timing with Cardio-OB team

7. Management during Delivery

 • Stable patients typically deliver vaginally

 • Account for changes in hemodynamics (e.g., placental auto-transfusion and relief of IVC compression ↑ preload)

 • A multi-disciplinary team is critical!

8. Management during Postpartum Period

 • Breast-feeding: no consensus on risk vs. benefit. - Some studies show no ↓ LV function. Avoid ARBs

 • ICD: Many patients will recover LVEF. Consider waiting ~6 months before 1° prevention. Possible role for wearable defibrillator as a "bridge to recovery"

 • Contraception counseling should be done on diagnosis or discharge. Avoid estrogen products early post-partum

9. Other Considerations

 • Thromboembolic complications are relatively common. In patients with LVEF (ESC), suggest prophylactic anticoagulation up to 8 weeks postpartum

 • Consider early mechanical support for patients clinically deteriorating on medical therapy, including inotropes

 • Bromocriptine, a dopamine agonist, prevents the release of prolactin. It is an investigative therapy in PPCM. If started, patients should be on a/c.

 • If no LVEF recovery (e.g., <50%), ESC guidelines recommend against future pregnancy. Risk of recurrence remains even if recovery.

 • During a future pregnancy, teratogenic GDMT meds (e.g., ACE/ARB) need to be stopped. Serial TTE and close follow-up with Cardio-OB team needed!



- Cardionerds - Karan Desai MD, MPH @karanpdesai



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