Peripartum cardiomyopathy (PPCM) or pregnancy-related cardiomyopathy is a form of heart failure that occurs during the last month of pregnancy or within the first five months postpartum, characterized by systolic dysfunction of the left ventricle in the absence of preexisting heart disease. The incidence of PPCM varies globally. In the United States, the incidence ranges from 1 in 1,000 to 1 in 8,000 deliveries, and it has been increasing over time. It is a significant cause of maternal morbidity and mortality worldwide.
Risk factors
Several risk factors are associated with the development of PPCM. These include hypertensive disorders of pregnancy, such as preeclampsia and eclampsia, which are present in one-third to one-half of PPCM cases. Other notable risk factors include multiparity, multiple gestations, advanced maternal age (over 30 years), diabetes and obesity. Additionally, there is a marked racial disparity, with Black women in the U.S. being four times more likely to develop PPCM compared to White women.
Signs and symptoms
The clinical presentation of PPCM can be challenging to distinguish from typical pregnancy-related symptoms. Common signs and symptoms include shortness of breath, inability to lie flat (orthopnea) and peripheral edema. Patients may also experience fatigue, palpitations and chest pain. Echocardiography is essential for diagnosis, revealing decreased myocardial function and left ventricle systolic dysfunction.
Risk reduction
To lower the risk of developing PPCM, it is essential to manage modifiable risk factors effectively. This includes controlling hypertensive disorders of pregnancy through appropriate medical management and monitoring. Ensuring adequate prenatal care to manage anemia and other comorbid conditions is also crucial. Genetic counseling and testing may be beneficial for women with a family history of cardiomyopathy, as genetic predisposition plays a role in the pathogenesis of PPCM.
Treatment options
The American College of Cardiology, in collaboration with the American Heart Association and the Heart Failure Society of America, emphasizes the importance of early recognition and multidisciplinary management of PPCM. This includes using guideline-directed medical therapy tailored to the patient's pregnancy or breastfeeding status. Standard heart failure treatments, such as beta-blockers, diuretics and vasodilators, are commonly employed, with careful consideration to avoid medications contraindicated during pregnancy. Bromocriptine, a dopamine agonist, has been investigated for its potential to improve outcomes in PPCM by suppressing prolactin secretion, which is thought to contribute to the pathogenesis of the disease. The evidence from European studies is promising. Currently, clinical trials in the U.S. aim to provide more definitive data.
In summary, PPCM is a serious condition with significant implications for maternal health. Recognizing and managing risk factors, early detection and treatment are key to improving outcomes for affected women.
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