Makindo Medical Notes

Related Subjects: | Dilated Cardiomyopathy | Hypertrophic Cardiomyopathy (HCM - HOCM) | Peripartum Cardiomyopathy | Restrictive Cardiomyopathy | Takotsubo Cardiomyopathy

Peripartum cardiomyopathy is a serious condition that requires prompt diagnosis and management to improve outcomes. With early intervention and appropriate treatment, many women can recover cardiac function, but long-term follow-up is essential.

About

• Typically occurs in the last month of pregnancy or within five months after delivery.
• Characterized by progressive dyspnoea, heart failure
• Left ventricular systolic dysfunction with an ejection fraction (EF) < 45%.

Higher Risks

• Maternal age ≥ 30 years
• Multiparity (having multiple pregnancies)
• African descent
• Pregnancy with multiple fetuses
• History of preeclampsia, eclampsia, or postpartum hypertension
• Maternal cocaine use
• Long-term use (> 4 weeks) of oral tocolytic therapy with beta-adrenergic agonists (e.g., terbutaline)

Clinical Features

• Breathlessness and fatigue
• Ankle oedema
• Palpitations and arrhythmias
• Cardioembolic events

Investigations

• FBC, U&E, LFT, CRP, and ECG: Routine blood tests and ECG help in initial evaluation.
• CXR: Shows cardiomegaly, pleural effusion, or pulmonary oedema. CXR is safe during pregnancy as it involves minimal radiation.
• Echocardiogram: Key diagnostic tool. It typically shows a reduced ejection fraction (< 45%) and may show left ventricular dilation.
• BNP or NT-proBNP: Elevated levels indicate heart failure.
• Cardiac biomarkers (e.g., troponins): May be mildly elevated.
• Cardiac MRI: Used to assess myocardial function and exclude other causes of cardiomyopathy.
• Coronary angiogram: May be needed to exclude ischaemic heart disease (IHD) in some cases.

Management

• ABCs: Prioritize airway, breathing, and circulation. Use diuretics and oxygen as needed.
• Anticoagulation: Consider for patients with severe left ventricular dysfunction (EF < 35%) to prevent thromboembolic events.
• Medication: Manage like any other cause of heart failure, but avoid ACE inhibitors (ACEI) and angiotensin receptor blockers (ARBs) during pregnancy due to fetal risk.
• Supportive care: May involve inotropes, intra-aortic balloon pumping, or even cardiac transplant in severe cases.
• Future pregnancies: There is a high risk of recurrence, so sterilization or contraception should be discussed.
• The exact aetiology is unknown, but deficiencies in selenium or other trace elements may play a role.

Pregnancy-Specific Care

• Delivery: Vaginal delivery is generally safer than Caesarean section, as it carries a lower risk of PE and endometritis.
• Preeclampsia: Always exclude preeclampsia in these patients.
• Anticoagulation: IV heparin is preferred over low-molecular-weight heparin (LMWH) due to better control.
• Avoid ACE inhibitors and ARBs: These medications can cause fetal anomalies; instead, use hydralazine and nitrates as alternatives, along with beta-blockers.
• Neonatal care: Ensure access to neonatal intensive care if needed.