❤️ Peripartum cardiomyopathy ✅

🤰❤️ Peripartum Cardiomyopathy (PPCM) is a rare, life-threatening cause of heart failure occurring in late pregnancy or the early postpartum period (last month of pregnancy up to 5 months postpartum). High clinical suspicion is essential because symptoms often overlap with normal pregnancy. Prompt diagnosis, guideline-directed management, and long-term follow-up improve outcomes and reduce recurrence risk.

⚡ Key Points

• Consider in any pregnant/postpartum woman with unexplained dyspnoea, orthopnoea, fatigue, or peripheral oedema.
• Always exclude other causes: pulmonary embolism, pneumonia, preeclampsia/eclampsia, valvular or ischaemic heart disease.
• Early stabilisation: ABCs → oxygen, cautious diuretics, continuous monitoring, involve obstetrics and cardiology.
• High risk of thromboembolism → anticoagulation may be indicated (IV unfractionated heparin in pregnancy; LMWH or warfarin postpartum).

🧬 Pathophysiology

• Exact mechanism unknown; multifactorial: oxidative stress → cleavage of prolactin to 16 kDa fragment → anti-angiogenic, pro-apoptotic effects on myocardium.
• Inflammatory cytokines, vascular dysfunction, genetic susceptibility (TTN mutations) contribute.
• Results in dilated cardiomyopathy phenotype with left ventricular systolic dysfunction and sometimes LV thrombus.

⚠️ Risk Factors

• Maternal age ≥30 years
• Multiparity 👩‍👧‍👦
• African or African-Caribbean ethnicity 🌍
• Multiple gestation (twins/triplets)
• Preeclampsia, eclampsia, postpartum hypertension
• Use of cocaine or long-term oral β-agonists (tocolytics)
• Previous PPCM in prior pregnancy → very high recurrence risk

🩺 Clinical Features

• Dyspnoea on exertion, orthopnoea, paroxysmal nocturnal dyspnoea
• Fatigue, reduced exercise tolerance
• Peripheral oedema, raised JVP, hepatomegaly
• Palpitations, arrhythmias, chest discomfort
• Thromboembolic events: stroke, systemic emboli (esp. if EF <35%)

🔎 Investigations

• Bloods: FBC, U&E, LFTs, CRP, BNP/NT-proBNP (↑ in HF), ± troponin
• ECG: Non-specific; may show sinus tachycardia, arrhythmias, conduction abnormalities
• CXR: Cardiomegaly, pulmonary congestion, pleural effusions (safe with shielding)
• Echocardiography: Diagnostic; LV systolic dysfunction (EF <45%), ± LV dilatation, RV involvement, thrombus
• Cardiac MRI: Tissue characterisation; exclude myocarditis
• Coronary angiography: Exclude ischaemic heart disease in older or high-risk patients

💊 Management (NICE/ESC Compliant)

• Acute stabilisation: ABCs, oxygen, cautious IV diuretics, high-dependency or ICU monitoring
• Heart failure therapy:
  • Beta-blockers: labetalol, metoprolol – safe in pregnancy
  • Vasodilators: hydralazine + nitrates for afterload reduction (avoid ACEI/ARBs antenatally)
  • Diuretics: judicious to reduce pulmonary congestion; avoid reducing placental perfusion
  • Avoid ACE inhibitors, ARBs, mineralocorticoid antagonists during pregnancy (teratogenic)
• Anticoagulation: indicated if EF <35% or LV thrombus; IV unfractionated heparin preferred antenatally; LMWH or warfarin postpartum (warfarin contraindicated during pregnancy)
• Advanced therapies: Inotropes, mechanical support (IABP, LVAD), cardiac transplantation in refractory cases
• Delivery planning: Vaginal delivery preferred if maternal haemodynamics stable; Caesarean for obstetric indications; tertiary centre with multidisciplinary input
• Postpartum care & counselling: Contraception advice; high recurrence risk in future pregnancies if EF not fully recovered; long-term cardiology follow-up

📉 Prognosis

• Partial or complete LV recovery in 50–70% within 6–12 months
• Persistent LV dysfunction → high morbidity, mortality, and recurrence risk
• Mortality: 10–20%, higher in severe LV dysfunction or delayed diagnosis

🩺 Student Case Examples

Case 1 – Postpartum Dyspnoea: 30F, 3 weeks postpartum, progressive breathlessness, orthopnoea, ankle swelling. Exam: raised JVP, basal crackles, oedema. Echo: LVEF 25%. Management: Diuretics, beta-blocker, ACEI/ARB postpartum, anticoagulation if EF <35%, cardiology follow-up. Avoid ACEI/ARBs during pregnancy.

Case 2 – Late Pregnancy Presentation: 36F, 36 weeks’ gestation, fatigue, palpitations, nocturnal breathlessness. Exam: tachycardia, displaced apex, basal crepitations. BNP ↑, Echo EF 30%. Management: Pregnancy-safe HF therapy: loop diuretics, beta-blocker, hydralazine + nitrates. Plan delivery in tertiary centre with obstetric and cardiology input. Avoid ACEI/ARBs and mineralocorticoid antagonists.

📚 References

• Sliwa K et al. Peripartum Cardiomyopathy: Current state of knowledge. Eur Heart J. 2010.
• ESC Guidance on Peripartum Cardiomyopathy
• NICE CKS – Heart Failure in Pregnancy Guidance