Makindo Medical Notes

🤰❤️ Peripartum cardiomyopathy (PPCM) is a rare but serious cause of heart failure in late pregnancy or the early postpartum period. Prompt recognition and treatment improve outcomes, but long-term follow-up is essential.

📖 About

• Onset: last month of pregnancy → up to 5 months postpartum.
• Defined by new left ventricular systolic dysfunction with LVEF < 45%.
• Symptoms overlap with normal pregnancy, so a high index of suspicion is needed.

⚠️ Risk Factors

• Maternal age ≥ 30 years
• Multiparity 👩‍👧‍👦
• African descent 🌍
• Multiple gestation (twins/triplets)
• Preeclampsia, eclampsia, or postpartum hypertension
• Cocaine use 🚬
• Long-term oral tocolytics (e.g. β-agonists such as terbutaline)

🩺 Clinical Features

• Dyspnoea, orthopnoea, fatigue
• Ankle oedema, raised JVP
• Palpitations, arrhythmias
• Thromboembolic events (stroke, systemic emboli)

🔎 Investigations

• Bloods: FBC, U&E, LFT, CRP, BNP/NT-proBNP (↑ in HF), ± troponin.
• ECG: Non-specific, may show arrhythmias.
• CXR: Cardiomegaly, pulmonary oedema, pleural effusions (safe in pregnancy with shielding).
• Echocardiography: Diagnostic – ↓ EF (<45%), ± LV dilatation.
• Cardiac MRI: Helpful for tissue characterisation.
• Coronary angiogram: Exclude ischaemic heart disease in older/risk patients.

💊 Management

• Acute care: ABCs, oxygen, diuretics, monitor in high-dependency setting.
• Anticoagulation: Indicated if EF < 35% (↑ embolic risk). – Pregnancy: IV unfractionated heparin preferred. – Postpartum: LMWH or warfarin acceptable (avoid warfarin in pregnancy).
• Heart failure therapy:
  • Avoid ACEI/ARBs in pregnancy (teratogenic). Use hydralazine + nitrates instead.
  • Beta-blockers (labetalol/metoprolol) are safe.
  • Diuretics with caution to avoid ↓ placental perfusion.
• Advanced support: Inotropes, intra-aortic balloon pump, LVAD, or transplant if refractory.
• Counselling: High recurrence risk → advise contraception; future pregnancies risky if EF not normalised.

🤱 Pregnancy-Specific Care

• Mode of delivery: Vaginal preferred unless obstetric indication for Caesarean.
• Always exclude preeclampsia in differential.
• Neonatal ICU preparedness is essential.
• Avoid ACEI/ARBs during pregnancy (safe postpartum if breastfeeding guidance allows).

📉 Prognosis

• Some women recover EF within 6–12 months 🎉.
• Persistent LV dysfunction → high morbidity, mortality, and recurrence risk in future pregnancies.
• Mortality can be up to 10–20% depending on setting and EF recovery.

📚 References

• Sliwa K et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy. Eur Heart J. 2010.
• ESC guidance on Peripartum Cardiomyopathy