Peripartum Cardiomyopathy
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Direct answer
Peripartum cardiomyopathy is heart failure with reduced ejection fraction that develops in the last month of pregnancy or within about five months after delivery, with no other cause identified. The diagnosis requires an LVEF below 45 percent together with left ventricular systolic dysfunction on echocardiography, and the ventricle is often but not always dilated. Management follows standard heart failure therapy adapted for pregnancy, with bromocriptine used in selected cases, and counselling about future pregnancy depends on whether the ejection fraction recovers.
What you must remember
- Definition: LVEF below 45 percent with no other cause, from the last month of pregnancy to about five months postpartum.
- Presentation: breathlessness, orthopnoea, oedema and fatigue, which are easily mistaken for normal pregnancy symptoms.
- Investigation: echocardiography confirms reduced LV function, with the ventricle often dilated, and other causes such as pre-eclampsia and valve disease are excluded.
- Risk factors: older maternal age, multiparity, twin pregnancy, hypertension and pre-eclampsia are commonly linked.
- Drugs in pregnancy: ACE inhibitors and ARBs are avoided as fetotoxic, with diuretics and hydralazine with nitrate used in their place.
- Anticoagulation: LV thrombus or severe dysfunction prompts anticoagulation with LMWH, since warfarin is embryopathic.
- Bromocriptine: a prolactin-inhibiting agent used in selected cases, with evidence limited to small studies.
- Recovery: EF recovers in many women, but persistent dysfunction predicts higher risk in later pregnancies.
Recognising peripartum heart failure early
A 29-year-old woman, three weeks after a normal vaginal delivery, develops breathlessness on walking, orthopnoea and ankle swelling. Her blood pressure is normal, and her echo shows an EF of 30 percent with a dilated left ventricle.
- Suspect the diagnosis: Breathlessness, orthopnoea or oedema in late pregnancy or the postpartum period should prompt echocardiography rather than reassurance.
- Exclude other causes: Pre-eclampsia, valvular disease, thyroid disease, myocardial ischaemia and pulmonary embolism are considered before the diagnosis is accepted.
- Assess severity: EF, LV thrombus, rhythm and haemodynamic status guide the level of monitoring, sometimes including intensive care.
- Start heart failure therapy: Diuretics and vasodilators, including hydralazine with a nitrate, are used, and beta-blockers are added once the patient is stable.
- Consider advanced options: Bromocriptine is considered in selected cases, while mechanical circulatory support or transplantation is reserved for severe, refractory failure.
- Counsel for future pregnancy: Recovery of EF guides advice, and persistent dysfunction calls for contraception and a clear recommendation against further pregnancy.
Where the exam tries to catch you
Peripartum questions focus on drug safety in pregnancy and counselling.
- Trap: Attributing postpartum breathlessness to normal changes. Correct: New heart failure in the peripartum period needs echocardiography, since it may be cardiomyopathy.
- Trap: Starting an ACE inhibitor in pregnancy. Correct: ACE inhibitors and ARBs are fetotoxic and avoided in pregnancy, so alternatives are used.
- Trap: Using warfarin for LV thrombus in pregnancy. Correct: Warfarin is embryopathic, so low molecular weight heparin is preferred.
- Trap: Telling a woman with recovered EF that a future pregnancy is risk-free. Correct: Recurrence risk must be counselled, with cardiology input.
Frequently asked questions
What EF cut-off defines peripartum cardiomyopathy?
Peripartum cardiomyopathy is defined by a left ventricular ejection fraction below 45 percent with no other cause found. The diagnosis applies from the last month of pregnancy to about five months after delivery.
Which heart failure drugs are avoided in pregnancy?
ACE inhibitors and ARBs are avoided in pregnancy-related heart failure because they are fetotoxic. Diuretics, hydralazine with nitrate and carefully chosen beta-blockers are used instead, and each choice is reviewed with the obstetric team.
What is the role of bromocriptine in peripartum cardiomyopathy?
Bromocriptine is a prolactin-inhibiting agent used in selected patients with peripartum cardiomyopathy. Evidence comes mainly from small studies, so it is considered case by case rather than as routine therapy.
Is a future pregnancy advised after peripartum cardiomyopathy?
Future pregnancy depends on whether the left ventricular ejection fraction has recovered, and recurrence risk is counselled individually. Women with persistent LV dysfunction are generally advised against further pregnancy, and the decision involves cardiology and obstetric teams.