Cardiopulmonary Postpartum

Most patients present soon after delivery especially in the first week postpartum. The symptoms are suggestive of heart failure, for example, orthopnea and paroxysmal nocturnal dyspnea. These symptoms are usually attributed to normal pregnancy and that is why a diagnosis of postpartum cardiomyopathy can be easily missed. Physical examination findings include tachycardia, elevated jugular venous pressure, bilateral pulmonary crackles due to pulmonary edema, third heart sound (S3) and displaced apical pulse. Severe cases may present with acute respiratory failure or cardiogenic shock and a need for close monitoring in the intensive care unit. 

Some of the most common risk factors for the development of postpartum cardiomyopathy are as follows:

·         Advanced maternal age (more cases reported in both extremes of age) 

·         High parity (71% of women diagnosed with PPCM had three or more prior pregnancies).  High gravidity

·         Twin pregnancy (more endemic in women with twin pregnancies)

·         Use of tocolytic therapy (greater than 4 weeks can cause silent ischemia).

·         African descent (more prevalent in the African population)

·         Poverty

·         Hypertension

·         Cocaine abuse

ECG may show non-specific changes like sinus tachycardia, interventricular delay and sometimes, LBBB pattern.

Echocardiography suffices to differentiate it from other causes and usually shows left ventricle dilatation of variable degrees, left ventricle systolic dysfunction, right ventricular and bi-atrial enlargement, mitral and tricuspid regurgitation, and pulmonary hypertension.. Echocardiography criteria to diagnose PPCM includes ejection fraction less than 45%, end-diastolic diameter greater than 2.7 cm/m2 and/or M-mode fractional shortening less than 30%.

Cardiac MRI can also be used to diagnose when an accurate estimation of the ejection fraction (EF) is required.

Treatment / Management

Treatment is usually supportive and directed toward the management of the heart failure symptoms. Standard heart failure therapy is used to optimize the patient's volume status. Beta-blockers and ACEIs are the most commonly used drugs and have shown to lower the mortality

 However, an ACEI is contraindicated in pregnant patients. Diuretics are often used to ease symptoms related to heart failure. Novel anti-heart failure medications, such as sacubitril/valsartan have been reported to improve heart failure symptoms in pregnancy-related cardiomyopathies.

Recent data suggest that an increase in oxidative stress during the peripartum period increases the formation of abnormal 16-kDa prolactin which induces toxic effects on cardiac myocyte. Bromocriptine, a dopamine receptor agonist with prolactin-blocking properties, decreases the effect of 16-kDa prolactin on cardiac myocyte and has been associated with better outcomes in small studies. Cardiac resynchronization therapy has also shown to improve ejection fraction and outcomes when medical therapy alone is ineffective. Prognosis

·         Postpartum cardiomyopathy, also known as peripartum cardiomyopathy (PPCM), is defined as new onset of heart failure between the last month of pregnancy and 5 months post delivery with no determinable cause. First described in a case series in 1937. Postpartum cardiomyopathy is a rare cause of heart failure. Bottom of Form

Postpartum Cardiomyopathy

AcK:--Ateeq Mubarik; Arshad Muhammad Iqbal.