Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM, also called pregnancy-associated cardiomyopathy) is a rarecause of heart failure (HF) that affects women late in pregnancy or in the early puerperium .Peripartum cardiomyopathy (PPCM) is defined as the development of systolic heart failure towardsthe end of pregnancy or in the months following pregnancy with left ventricular ejection fraction(LVEF) generally less than 45 percent in the absence of another identifiable cause of heart failure.PPCM is rarely seen before 36 weeks of gestation, and affected patients usually present during thefirst month postpartum. The etiology of PPCM is unknown, with possible causes including angiogenicimbalance, altered prolactin processing, genetic, inflammatory, hormonal, hemodynamic, andautoimmune factors. A number of risk factors for PPCM have been identified, including greater age,multiple gestation, African descent, and a history of preeclampsia, eclampsia, or postpartumhypertension. The clinical presentation of PPCM is variable and similar to that in other forms ofsystolic heart failure due to cardiomyopathy. The echocardiogram generally reveals global reductionin LV systolic function with LVEF nearly always <45 percent. The LV is frequently but not alwaysdilated. The role of bromocriptine therapy in PPCM is controversial. While preliminary data havesuggested a benefit from bromocriptine in patients with PPCM, further trials are needed to establishsafety and efficacy. Until additional data are available, we suggest not routinely using bromocriptinefor patients with PPCM. Some other experts advocate using bromocriptine routinely in this setting.Decisions regarding the timing and mode of delivery in PPCM should be made based upon combinedinput from cardiology, obstetrics, anesthesiology, and neonatology services. Prompt delivery issuggested in women with PPCM with advanced HF. All women with PPCM should receivecounseling on the potential risk of recurrence with future pregnancies. We suggest that women witha history of PPCM who have persistent LV dysfunction (LV ejection fraction <50 percent) or LVejection fraction ≤25 percent at diagnosis be advised to avoid pregnancy due to the risk of HFprogression and death.