Maternal Cardiac Care - Chapter 8: Peripartum Cardiomyopathy

Peripartum cardiomyopathy, a disorder specific to pregnancy, is one of the most feared complications for pregnant women and their medical care teams. However, relatively little is understood about its underlying pathophysiology, risk factors, and early warning signs. The diagnostic criteria include development of systolic heart failure in the last month of pregnancy or the first 6 months postpartum and defined echocardiographic criteria of systolic heart failure. Risk factors include multifetal gestation, high gravidity, extremes of reproductive age, and prolonged tocolysis. The etiology involves activation of immune system inflammatory pathways. There is a genetic predisposition. Prolactin metabolites, which cause vasoconstriction, apoptosis, inflammation, and capillary destruction, as well as diminished cardiomyocyte metabolism, diminished contractility, and cardiac chamber dilation, are involved. Treatment for heart failure is the same as in nonpregnant women except that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should not be used in pregnancy. Anticoagulation is recommended because pregnancy is a hypercoagulable state, and stasis in the left ventricle promotes thrombus formation. The outlook for recovery is good, with more than 50% of woman regaining normal heart function. However, subsequent pregnancies are associated with a high risk of recurrence (20% in women with full recovery), and women with less than full recovery should be discouraged from future pregnancies.