Peripartum Cardiomyopathy -Plan of tenement & follow up??

What will be the long term therapy for survivors of Peripartum cardiomyopathy ??  Ans:-In long standing cases : say after 2-3 weeks after however  recovery :-A) Thromboprophylaxis Anticoagulants are mandatory if there is severe impaired left ventricular dysfunction intracardiac thrombus or arrhythmias. B) To continue Conventional treatment for heart failure including diuretics vasodilators cardio selective  B blockers or B blockers with arteriolar vasodilating action digoxin inotropes and C) after delivery angiotensin converting enzyme inhibitors. D) Immunosppressivse therapy may be considered in cases with myocarditis documented by endomyocardial biopsy that fail to improve within 2 weeks of initiation of standard heart failure therapy .E)  Bromocriptine has been suggested in view of the link with a pathogenic form of prolactin  F) .Intra – aortic balloon pumps and left ventricular assist devices may provide temporary support. F) Though seem ridiculous for me (an obstetrician but there has been occasions where in Prepartum cardiomyopathy eventually got cured by  Cardiac transplantation . Case reports are there . Prognosis and recurrence .Maternal mortality rate has decreased from 40% in older studies to 9% -15% in more recent series. One study documented a 95% 5 year survival. Many case fatalities occur close to presentation and cardiomyopathy causes about 25% of cardiac maternal deaths in the united Kingdom. About 50% of patients make a spontaneous and full recovery.Prognosis depends on normalization of left ventricular size and function within 6 months after delivery . Mortality is increased in those with persistent left ventricular dysfunction. Women should be counselled against further pregnancy if left ventricular size or function does not return to normal since there is a significant risk of recurrence worsening heart failure and death in subsequent pregnancies. Adequate contraception should be advised such as the intrauterine progestogen only system or the subdermal progestogen only implant .For those whose cardiomyopathy resolves. The recurrence risk is not known but appears to be lower . However the contractile reserves may be impaired echocardiogram may be appropriate pre- pregnancy .Subsequent pregnancies  are high risk and require collaborative care