Peripartum cardiomyopathy
Peripartum cardiomyopathy is heart failure with reduced ejection fraction of no other identifiable cause, developing from the last month of pregnancy to five months postpartum. It is diagnosed by echocardiographic LVEF below 45% in the correct time window after excluding other causes, and treated as heart failure with pregnancy-safe drug choices plus bromocriptine as an adjunct.
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What this article covers
- Overview
Definition: peripartum cardiomyopathy, also called pregnancy-associated cardiomyopathy, is a relatively rare form of systolic heart failure with no other identifiable cause, developing between the…
- Epidemiology
Timing distribution: most cases present in the first month after delivery, though the defined window spans the last month of pregnancy through 5 months postpartum.
- Risk factors
Multiparity: a greater number of prior pregnancies increases risk.
- Pathophysiology
Cause unknown and multifactorial: multiple mechanisms have been proposed, but none has been validated as the sole cause.
- Clinical features
Heart failure syndrome in the correct time window: dyspnea, orthopnea, paroxysmal nocturnal dyspnea, pedal edema, and low exercise tolerance arising in the last month of pregnancy or within 5 months of delivery is the hallmark presentation.
- Differential diagnosis
Pulmonary embolism: presents with dyspnea and hypoxia, but PE causes right-sided heart failure from acute right ventricular strain rather than the biventricular systolic dysfunction and reduced LVEF…
- Diagnosis
Clinching basis: peripartum cardiomyopathy is diagnosed when echocardiography shows LVEF below 45 percent, symptom onset falls between the last month of pregnancy and 5 months postpartum, and no other cause of heart failure is identified.
- Management
First, treat as standard heart failure with pregnancy-safe agents: initiate guideline-directed heart failure therapy using drugs safe in pregnancy and lactation; avoid teratogenic agents throughout pregnancy.
- Complications
Death: mortality of about 10 percent at 2 years.
- Prognosis
Highly variable course: outcomes range from rapid, complete recovery of ejection fraction to end-stage heart failure requiring transplantation or death.
- Prevention
Avoid future pregnancy with persistent LV dysfunction: counsel against a subsequent pregnancy when LVEF remains persistently below 50 percent, and especially below 25 percent, given the risk of relapse and sudden death.
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Related articles
- Dilated cardiomyopathy
Dilated cardiomyopathy is left ventricular (often biventricular) dilation with systolic dysfunction not explained by loading conditions or coronary disease, from genetic, viral, toxic, or peripartum causes, presenting as heart failure with reduced ejection fraction. Diagnosis is by echocardiography with a workup for reversible causes, and treatment is guideline-directed heart-failure therapy with device therapy for high-risk patients.
- Acute heart failure
Acute heart failure is the rapid onset or worsening of heart failure symptoms requiring urgent therapy, most often pulmonary congestion from a precipitant such as ischemia, arrhythmia, or nonadherence. Management is oxygen, intravenous diuretics, and vasodilators for the congested-but-perfused patient, with inotropes or support for the hypoperfused patient.
- Heart failure
Heart failure is a clinical syndrome of impaired cardiac filling or ejection causing congestion and reduced perfusion, classified by ejection fraction. Diagnosis integrates symptoms, signs, natriuretic peptides, and echocardiography, and treatment of reduced-ejection-fraction disease is quadruple guideline-directed therapy, with device therapy and cause-specific management.
- Myocarditis
Myocarditis is inflammation of the myocardium, most often postviral or immune-mediated, presenting across a spectrum from a mild chest-pain syndrome mimicking myocardial infarction to fulminant heart failure and arrhythmia. Diagnosis relies on cardiac MRI (or biopsy for severe or refractory cases), and treatment is supportive heart-failure care, with cause-specific immunosuppression for giant cell, checkpoint-inhibitor, and autoimmune myocarditis.