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Peripartum Cardiomyopathy Matthew Voth M.D. WCGME  Dept. of Ob/Gyn – PGY-1
Case Presentation <ul><li>N.A.  22 y.o. G1 P0 @ 40 WGA presented to LDR with chief complaint:  contractions </li></ul><ul>...
Antepartum  <ul><li>109 lbs on initial exam.  Gained 27 lbs during pregnancy </li></ul><ul><li>28 week Hgb 10.1.  Pt unabl...
Case Presentation cont.. <ul><li>Initial Vital signs: BP 134/78, P-60 R-16 </li></ul><ul><li>Progressed along labor curve ...
Emergent C/S <ul><li>No complications </li></ul><ul><li>EBL 1000cc </li></ul><ul><li>APGARS 8/9 </li></ul><ul><li>Tight nu...
Postpartum Care <ul><li>Hgb on admission 11.5 gm/dl </li></ul><ul><li>6 hours post-op 7.4 gm/dl </li></ul><ul><li>800cc LR...
Postpartum Day #2 <ul><li>A.M. Hgb 7.4 gm/dl </li></ul><ul><li>Pt. Not tachycardic, BP’s stable 130’s/70’s </li></ul><ul><...
Postpartum Care cont… <ul><li>Pt. Remained asymptomatic.  </li></ul><ul><li>Vital signs remained stable until PPD#3 </li><...
Postpartum Care cont…. <ul><li>PPD #4, Hgb 7.4 </li></ul><ul><li>BP 138/85, pt. Asymptomatic </li></ul><ul><li>Discharged ...
ER Visit PPD#7 <ul><li>4 days after dismissal pt. Returned to ER with complaints of: </li></ul><ul><ul><li>Shortness of br...
Physical Exam <ul><li>BP 143/100  </li></ul><ul><li>Pulse 83, regular </li></ul><ul><li>RR 19 </li></ul><ul><li>O2 sat 100...
Cardiology consult <ul><li>EKG- normal </li></ul><ul><li>BMP – WNL </li></ul><ul><li>CBC – Hgb 8.1 gm/dl </li></ul><ul><li...
Cardiology Consult cont…. <ul><li>PE: reported an S3 gallop </li></ul><ul><li>Lasix 40 mg IV x1 then 20mg PO daily </li></...
3-Women’s <ul><li>Post admit day 1- pt reportedly much improved.  Breathing easier.  Ambulating. Voiding >90cc/hour.  </li...
Review of Cardiac Changes in Pregnancy <ul><li>Increase in blood volume  </li></ul><ul><ul><li>As early as 4 th  week </li...
Review cont…. <ul><li>Increase in TBV due to: </li></ul><ul><ul><li>Increased vascular capacitance </li></ul></ul><ul><ul>...
Review cont…. <ul><li>Elevation of CO rises 30-50 % </li></ul><ul><li>Due to 3 important factors: </li></ul><ul><ul><li>Pr...
                                                                                                                          ...
*Chapman et al.  Kidney Int 1998; 54:2056                                                                                 ...
What is a Cardiomyopathy?? <ul><li>Characterized by dilation and impaired contraction of one or both ventricles. </li></ul...
Cont….. <ul><li>Overall responsible for 10,000 deaths and 46,000 hospitalizations each year </li></ul><ul><li>Wide age ran...
 
*Felker et al. N Engl J Med 2000; 342:1077
Peripartum Cardiomyopathy <ul><li>4% of all cardiomyopathies </li></ul><ul><li>1:3000-4000 preg. </li></ul><ul><li>Dilated...
Should we be concerned?? <ul><li>Yes! </li></ul><ul><li>CDC  Pregnancy Related Mortality Surveillance 1991-1999 </li></ul>...
Etiology <ul><li>Multiple studies have attempted to elucidate a distinct etiology…..all have failed </li></ul><ul><li>Theo...
Myocarditis?? <ul><li>Nairobi Study1986 </li></ul><ul><ul><li>11 African women with PPCM </li></ul></ul><ul><ul><li>Endoca...
Myocarditis? Cont… <ul><li>Another study: </li></ul><ul><ul><li>84 women with cardiomyopathies </li></ul></ul><ul><ul><li>...
Myocarditis? Cont…. <ul><li>3 rd  Study: </li></ul><ul><li>18 patients with PPCM </li></ul><ul><ul><li>14 due to myocardit...
Myocarditis? Cont…. <ul><li>1994 Retrospective study </li></ul><ul><ul><li>34 patients diagnosed with PPCM </li></ul></ul>...
Abnormal Immune Response? <ul><li>Maternal immunologic response to a fetal antigen? </li></ul><ul><ul><li>Fetal cells may ...
Immune Response? Cont…. <ul><li>Disproved 1990., Nigerian Study </li></ul><ul><ul><li>39 women with PPCM </li></ul></ul><u...
Genetics <ul><li>Several case reports published </li></ul><ul><ul><li>1963,  Pierce et al.  reported that 3 of 17 patients...
Genetics cont…. <ul><li>Also, 1976  Strung  documented male relatives of female patients with PPCM as also having cardiomy...
Risk Factors <ul><li>Age >30 years old </li></ul><ul><li>Multiparity </li></ul><ul><li>African Descent </li></ul><ul><li>M...
Criteria for Diagnosis <ul><li>4 Criteria </li></ul><ul><ul><li>Development of Heart failure in the last month of pregnanc...
Clinical Presentation <ul><li>Symptoms: </li></ul><ul><ul><li>Paroxysmal Nocturnal Dyspnea </li></ul></ul><ul><ul><li>Dysp...
 
Timing of Diagnosis <ul><li>Dx. Requires being in the last month of pregnancy </li></ul><ul><li>If earlier, consider under...
Diagnosis <ul><li>EKG </li></ul><ul><li>Two-dimensional echocardiogram </li></ul><ul><li>CXR </li></ul><ul><li>Lab:  CBC, ...
EKG Changes <ul><li>Sinus Tachycardia </li></ul><ul><li>Nonspecific ST changes </li></ul><ul><li>LV Hypertrophy </li></ul>
Chest X-ray <ul><li>Pulmonary Edema </li></ul><ul><li>Venous congestion </li></ul><ul><li>Enlarged Cardiac Silhouette </li...
Echocardiogram <ul><li>Spherical LV </li></ul><ul><li>Mitral and Tricuspid regurgitation </li></ul><ul><li>Left Atrial enl...
Case Presentation  <ul><li>EKG  WNL </li></ul><ul><li>CXR-mild edema </li></ul><ul><li>Echo: </li></ul><ul><ul><li>EF 47% ...
Treatment <ul><li>Delivery  </li></ul><ul><li>Similar to other forms of CHF </li></ul><ul><ul><li>Diuretics </li></ul></ul...
Pregnancy Drug Class Review <ul><li>Category A:  Controlled studies in pregnant women fail to demonstrate a risk to the fe...
Drug class cont….. <ul><li>Category C:    Studies in women and animals are not available   or   studies in animals have re...
Drug class cont…. <ul><li>Category X:  Highly unsafe: risk of use outweighs any potential benefit.  Drugs in this category...
Drugs <ul><li>Digoxin Class C </li></ul><ul><ul><li>Symptomatic control </li></ul></ul><ul><ul><li>Requires level monitori...
Diuretics <ul><li>Lasix Class C </li></ul><ul><ul><li>Reserved for cardiac conditions </li></ul></ul><ul><ul><li>Not recom...
Vasodilators <ul><li>Hydralazine Class C </li></ul><ul><ul><li>Compatible with breastfeeding  </li></ul></ul><ul><li>ACE I...
Beta-Blockers <ul><li>Class C </li></ul><ul><li>Compatible with breast feeding </li></ul><ul><li>Has been shown to cause I...
Anticoagulants <ul><li>Heparin Class C </li></ul><ul><ul><li>Short half life-can be discontinued prior to delivery to prev...
Other Therapy <ul><li>IV Immune Globulin </li></ul><ul><ul><li>One retrospective study </li></ul></ul><ul><ul><ul><li>6 PP...
Other Therapy cont…. <ul><li>Cardiac Transplant </li></ul><ul><ul><li>Estimated that transplant is performed in up to 1/3 ...
Differential Diagnosis <ul><li>PIH </li></ul><ul><ul><li>However, HF associated with PIH represents a diastolic failure, v...
Prognosis <ul><li>Mortality estimates range from 25-50%. </li></ul><ul><li>Most deaths occur within 3 months postpartum </...
Prognosis cont… <ul><li>India study </li></ul><ul><ul><li>20 pts. PPCM </li></ul></ul><ul><ul><li>Followed for 14 months p...
 
 
Future Pregnancies?? <ul><li>Opinions widely vary </li></ul><ul><li>Most experts agree that patients should avoid future p...
Literature <ul><li>One study: </li></ul><ul><ul><li>NEJM 2001 – USC </li></ul></ul><ul><ul><ul><li>44 Patients PPCM underg...
Future Pregnancies cont… <ul><li>Highly Individual </li></ul><ul><ul><li>Patient education of risks </li></ul></ul><ul><ul...
Summary <ul><li>PPCM –Dilated myopathy </li></ul><ul><li>1:3000-4000 pregnancies </li></ul><ul><li>Maternal mortality Incr...
References <ul><li>Demakis, JG, Rahimtoola, SH, Sutton, GC, et al. Natural course of peripartum cardiomyopathy. Circulatio...
References cont… <ul><li>Pearl, W. Familial occurrence of peripartum cardiomyopathy. Am Heart J 1995; 129:421  </li></ul><...
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Transcript of "Peripartum Cardiomyopathy"

  1. 1. Peripartum Cardiomyopathy Matthew Voth M.D. WCGME Dept. of Ob/Gyn – PGY-1
  2. 2. Case Presentation <ul><li>N.A. 22 y.o. G1 P0 @ 40 WGA presented to LDR with chief complaint: contractions </li></ul><ul><li>2/85/-1 on initial exam </li></ul><ul><li>3/90/-1 recheck 1 hour later </li></ul><ul><li>Admitted to BCC for Expectant Management of Labor </li></ul>
  3. 3. Antepartum <ul><li>109 lbs on initial exam. Gained 27 lbs during pregnancy </li></ul><ul><li>28 week Hgb 10.1. Pt unable to tolerate Niferex during pregnancy </li></ul><ul><li>C/O back pain requiring prn Lortab </li></ul><ul><li>Otherwise unremarkable antepartum care </li></ul>
  4. 4. Case Presentation cont.. <ul><li>Initial Vital signs: BP 134/78, P-60 R-16 </li></ul><ul><li>Progressed along labor curve for several hours with occasional variable decel. </li></ul><ul><li>Good BTBV, overall reassuring </li></ul><ul><li>At 0500 called to evaluate prolonged deceleration, pt was rushed to OR for emergent C/S. </li></ul>
  5. 5. Emergent C/S <ul><li>No complications </li></ul><ul><li>EBL 1000cc </li></ul><ul><li>APGARS 8/9 </li></ul><ul><li>Tight nuchal cord </li></ul><ul><li>Pt. To recovery in </li></ul><ul><li>stable condition </li></ul>
  6. 6. Postpartum Care <ul><li>Hgb on admission 11.5 gm/dl </li></ul><ul><li>6 hours post-op 7.4 gm/dl </li></ul><ul><li>800cc LR bolus given </li></ul><ul><li>Typed and Crossed for 2 Units </li></ul><ul><li>Hbg rechecked 8 hours later, 6.8 gm/dl </li></ul><ul><li>500cc bolus given </li></ul>
  7. 7. Postpartum Day #2 <ul><li>A.M. Hgb 7.4 gm/dl </li></ul><ul><li>Pt. Not tachycardic, BP’s stable 130’s/70’s </li></ul><ul><li>Urine output >100cc/hour </li></ul><ul><li>IV DC’d PPD #2 </li></ul>
  8. 8. Postpartum Care cont… <ul><li>Pt. Remained asymptomatic. </li></ul><ul><li>Vital signs remained stable until PPD#3 </li></ul><ul><li>4 consecutive BP’s >140/90 and HR >110 </li></ul><ul><li>Pt. Tol PO well. IV not restarted </li></ul><ul><li>C/O Headache </li></ul><ul><li>PIH labs ordered - WNL </li></ul>
  9. 9. Postpartum Care cont…. <ul><li>PPD #4, Hgb 7.4 </li></ul><ul><li>BP 138/85, pt. Asymptomatic </li></ul><ul><li>Discharged home </li></ul>
  10. 10. ER Visit PPD#7 <ul><li>4 days after dismissal pt. Returned to ER with complaints of: </li></ul><ul><ul><li>Shortness of breath-more pronounced when lying down </li></ul></ul><ul><ul><li>Chest heaviness when lying down </li></ul></ul><ul><ul><li>Lightheadedness x 2 days </li></ul></ul>
  11. 11. Physical Exam <ul><li>BP 143/100 </li></ul><ul><li>Pulse 83, regular </li></ul><ul><li>RR 19 </li></ul><ul><li>O2 sat 100% on 1L </li></ul><ul><li>2+ edema LE’sL </li></ul><ul><li>Lungs crackles heard at bases bilaterally </li></ul><ul><li>PIH labs ordered </li></ul><ul><li>20 mg Lasix given in ER </li></ul><ul><li>Admitted to 3-WH </li></ul><ul><li>Cardiology consulted </li></ul><ul><li>Dx: R/O cardiomyopathy </li></ul>
  12. 12. Cardiology consult <ul><li>EKG- normal </li></ul><ul><li>BMP – WNL </li></ul><ul><li>CBC – Hgb 8.1 gm/dl </li></ul><ul><li>TSH - WNL </li></ul><ul><li>Troponin I –WNL </li></ul><ul><li>BNP – 949 normal range (<100 pg/ml) </li></ul><ul><li>Echo – Dilated cardiomyopathy </li></ul>
  13. 13. Cardiology Consult cont…. <ul><li>PE: reported an S3 gallop </li></ul><ul><li>Lasix 40 mg IV x1 then 20mg PO daily </li></ul><ul><li>Lisinopril 5mg PO x1 then 10mg PO BID </li></ul><ul><li>KCl 40mg PO x1 then 10 mg PO BID </li></ul><ul><li>Ativan 0.5mg PO prn </li></ul><ul><li>Daily I’s and O’s </li></ul>
  14. 14. 3-Women’s <ul><li>Post admit day 1- pt reportedly much improved. Breathing easier. Ambulating. Voiding >90cc/hour. </li></ul><ul><li>Edema diminishing </li></ul><ul><li>Post admit day 2 – pt. Discharged home, asymptomatic. Vital signs stable. 3 kg weight loss. </li></ul>
  15. 15. Review of Cardiac Changes in Pregnancy <ul><li>Increase in blood volume </li></ul><ul><ul><li>As early as 4 th week </li></ul></ul><ul><ul><li>10-15% at 6-12 weeks </li></ul></ul><ul><ul><li>Rises rapidly thru 32-34 weeks then a modest rise </li></ul></ul><ul><ul><li>Net result = 1100 – 1600 cc increase or 30-50% above baseline </li></ul></ul><ul><ul><li>* Lund et al. Am J Obstet Gynecol 1967; 98:393 </li></ul></ul>
  16. 16. Review cont…. <ul><li>Increase in TBV due to: </li></ul><ul><ul><li>Increased vascular capacitance </li></ul></ul><ul><ul><li>Systemic vasodilation </li></ul></ul><ul><ul><li>… .as opposed to pure blood volume expansion </li></ul></ul><ul><ul><li>Renin is increased and ANP decreased </li></ul></ul><ul><ul><li>( would suspect alternate with pure BV expansion) </li></ul></ul><ul><ul><li>Shier et al N Eng J Med 1988; 319:1127 </li></ul></ul>
  17. 17. Review cont…. <ul><li>Elevation of CO rises 30-50 % </li></ul><ul><li>Due to 3 important factors: </li></ul><ul><ul><li>Preload is increased due to increase in TBV </li></ul></ul><ul><ul><li>Afterload is reduced due to decreased SVR </li></ul></ul><ul><ul><li>Maternal HR rises 15-20 bpm </li></ul></ul><ul><ul><li>Robson, et al. Am J Physiol 1989; 256:H1060 . </li></ul></ul>
  18. 18.                                                                                                                                         
  19. 19. *Chapman et al. Kidney Int 1998; 54:2056                                                                                                                                            
  20. 20. What is a Cardiomyopathy?? <ul><li>Characterized by dilation and impaired contraction of one or both ventricles. </li></ul><ul><li>Affects systolic funtion </li></ul><ul><li>Pt. May or my not develop overt heart failure. </li></ul><ul><li>*Richardson et al. Circulation 1996 93:841 </li></ul>
  21. 21. Cont….. <ul><li>Overall responsible for 10,000 deaths and 46,000 hospitalizations each year </li></ul><ul><li>Wide age range 20-60 </li></ul><ul><li>*Dec et al. N Engl J Med 1994; 331:1564 </li></ul><ul><li>Common Sx: </li></ul><ul><ul><li>Progressive dyspnea with exertion </li></ul></ul><ul><ul><li>Impaired exercise capacity </li></ul></ul><ul><ul><li>Orthopnea </li></ul></ul><ul><ul><li>Paroxysmal nocturnal dyspnea </li></ul></ul><ul><ul><li>Peripheral edema </li></ul></ul>
  22. 23. *Felker et al. N Engl J Med 2000; 342:1077
  23. 24. Peripartum Cardiomyopathy <ul><li>4% of all cardiomyopathies </li></ul><ul><li>1:3000-4000 preg. </li></ul><ul><li>Dilated Cardiomyopathy </li></ul>
  24. 25. Should we be concerned?? <ul><li>Yes! </li></ul><ul><li>CDC Pregnancy Related Mortality Surveillance 1991-1999 </li></ul><ul><ul><li>Leading Causes of Maternal Mortality: </li></ul></ul><ul><ul><ul><li>Embolism – 20% </li></ul></ul></ul><ul><ul><ul><li>Hemorrhage – 17% </li></ul></ul></ul><ul><ul><ul><li>Hypertension – 16% </li></ul></ul></ul><ul><ul><ul><li>Peripartum Cardiomyopathy- 9%*** </li></ul></ul></ul>
  25. 26. Etiology <ul><li>Multiple studies have attempted to elucidate a distinct etiology…..all have failed </li></ul><ul><li>Theories: </li></ul><ul><ul><li>Myocarditis </li></ul></ul><ul><ul><li>Abnormal Immune Response </li></ul></ul><ul><ul><li>Genetics </li></ul></ul><ul><ul><li>High postpartum salt intake </li></ul></ul>
  26. 27. Myocarditis?? <ul><li>Nairobi Study1986 </li></ul><ul><ul><li>11 African women with PPCM </li></ul></ul><ul><ul><li>Endocardial biopsies done on all eleven </li></ul></ul><ul><ul><ul><li>5 showed evidence of “healing myocarditis” </li></ul></ul></ul><ul><ul><ul><ul><li>Presence of inflammatory cells </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Necrosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fibrous remodeling </li></ul></ul></ul></ul><ul><ul><li>9 patients finished study </li></ul></ul><ul><ul><ul><li>75% of myocarditis group developed persistent heart failure </li></ul></ul></ul><ul><ul><ul><li>80% of patients without myocarditis improved </li></ul></ul></ul><ul><ul><ul><li>* Sanderson et al. Br Heart J 1986: 56:285 </li></ul></ul></ul>
  27. 28. Myocarditis? Cont… <ul><li>Another study: </li></ul><ul><ul><li>84 women with cardiomyopathies </li></ul></ul><ul><ul><li>14 diagnosed as being PPCM </li></ul></ul><ul><ul><ul><li>29% of patients with PPCM were found to have myocarditis </li></ul></ul></ul><ul><ul><ul><li>Only 9% of idiopathic CM related to myocarditis </li></ul></ul></ul><ul><li>* O’Connell et al. J AM Coll Cardiol 1986; 8:52 </li></ul>
  28. 29. Myocarditis? Cont…. <ul><li>3 rd Study: </li></ul><ul><li>18 patients with PPCM </li></ul><ul><ul><li>14 due to myocarditis </li></ul></ul><ul><ul><li>10 of these received immunosuppressive Tx over 6-8 weeks, then tapered over 6-8 weeks </li></ul></ul><ul><ul><ul><li>9 of 10 improved on therapy </li></ul></ul></ul><ul><ul><ul><li>However, 4 of 4 not receiving therapy also improved </li></ul></ul></ul><ul><ul><ul><li>* Midei et al. Circulation 1990; 81:922 </li></ul></ul></ul>
  29. 30. Myocarditis? Cont…. <ul><li>1994 Retrospective study </li></ul><ul><ul><li>34 patients diagnosed with PPCM </li></ul></ul><ul><ul><li>Researches found lower incidence of myocarditis than previously reported </li></ul></ul><ul><ul><ul><li>8.8 % due to myocarditis </li></ul></ul></ul><ul><ul><li>Why the discrepancy?? </li></ul></ul><ul><ul><li>* Rizeq et al. Am J Cardiol 1994; 74:474 </li></ul></ul>
  30. 31. Abnormal Immune Response? <ul><li>Maternal immunologic response to a fetal antigen? </li></ul><ul><ul><li>Fetal cells may escape into the maternal circulation without being rejected. </li></ul></ul><ul><ul><li>May become lodged in cardiac tissue. </li></ul></ul><ul><ul><li>May trigger immune response </li></ul></ul><ul><ul><ul><li>* Nelson et al. J Am Med Womens Assoc 1998; 53:31 </li></ul></ul></ul>
  31. 32. Immune Response? Cont…. <ul><li>Disproved 1990., Nigerian Study </li></ul><ul><ul><li>39 women with PPCM </li></ul></ul><ul><ul><li>No differences between subjects and controls in levels of: </li></ul></ul><ul><ul><ul><li>Serum Immunoglobulins </li></ul></ul></ul><ul><ul><ul><li>Circulating Immune Complexes </li></ul></ul></ul><ul><ul><ul><li>Cardiac muscle antibodies </li></ul></ul></ul><ul><ul><ul><li>*Cenac et al. Int J Cardiol 1990; 26:49 </li></ul></ul></ul>
  32. 33. Genetics <ul><li>Several case reports published </li></ul><ul><ul><li>1963, Pierce et al. reported that 3 of 17 patients with PPCM had definitive FH of same condition </li></ul></ul><ul><ul><li>1984 Voss et al. reported a patient who died from PPCM as did her mother and two of her sisters </li></ul></ul><ul><ul><li>1993 Massad et al. reported 16 y.o girl with PPCM following molar preg. Sister later received cardiac transplant for PPCM. </li></ul></ul><ul><ul><li>Cont…. </li></ul></ul>
  33. 34. Genetics cont…. <ul><li>Also, 1976 Strung documented male relatives of female patients with PPCM as also having cardiomyopathies. </li></ul><ul><li>Hard to retrospectively study…. </li></ul><ul><ul><li>Can not determine every patient who develops PPCM was completely healthy before pregnancy. </li></ul></ul><ul><ul><li>* Pearl Am Heart J 1995;129:421-2 </li></ul></ul>
  34. 35. Risk Factors <ul><li>Age >30 years old </li></ul><ul><li>Multiparity </li></ul><ul><li>African Descent </li></ul><ul><li>Maternal cocaine abuse </li></ul><ul><li>Long term tocolytic therapy (>4weeks) </li></ul><ul><li>Pregnancy with multiple fetuses </li></ul><ul><li>History of Preeclampsia, eclampsia, or postpartum HTN </li></ul>
  35. 36. Criteria for Diagnosis <ul><li>4 Criteria </li></ul><ul><ul><li>Development of Heart failure in the last month of pregnancy, or within 5 months postpartum </li></ul></ul><ul><ul><li>Absence of a determinable cause for cardiac failure </li></ul></ul><ul><ul><li>Absence of heart disease before last month of pregnancy </li></ul></ul><ul><ul><li>Left Ventricle impairment demonstrated on Echo </li></ul></ul>
  36. 37. Clinical Presentation <ul><li>Symptoms: </li></ul><ul><ul><li>Paroxysmal Nocturnal Dyspnea </li></ul></ul><ul><ul><li>Dyspnea on Exertion </li></ul></ul><ul><ul><li>Cough </li></ul></ul><ul><ul><li>Orthopnea </li></ul></ul><ul><ul><li>Chest Pain </li></ul></ul><ul><ul><li>Abdominal Discomfort </li></ul></ul><ul><ul><li>Palpitation </li></ul></ul><ul><li>Signs: </li></ul><ul><ul><li>Cardiomegaly </li></ul></ul><ul><ul><li>Gallop Rhythm </li></ul></ul><ul><ul><li>Edema </li></ul></ul><ul><ul><li>Holosystolic murmur </li></ul></ul>
  37. 39. Timing of Diagnosis <ul><li>Dx. Requires being in the last month of pregnancy </li></ul><ul><li>If earlier, consider underlying heart disease (ischemic, valvular, or myopathic) </li></ul><ul><li>2 nd trimester burden </li></ul>
  38. 40. Diagnosis <ul><li>EKG </li></ul><ul><li>Two-dimensional echocardiogram </li></ul><ul><li>CXR </li></ul><ul><li>Lab: CBC, CMP, BNP, TSH, Ferritin </li></ul><ul><li>If persistent past initial therapy: </li></ul><ul><ul><li>Cardiac catheterization </li></ul></ul><ul><ul><li>?Myocardial biopsy </li></ul></ul>
  39. 41. EKG Changes <ul><li>Sinus Tachycardia </li></ul><ul><li>Nonspecific ST changes </li></ul><ul><li>LV Hypertrophy </li></ul>
  40. 42. Chest X-ray <ul><li>Pulmonary Edema </li></ul><ul><li>Venous congestion </li></ul><ul><li>Enlarged Cardiac Silhouette </li></ul><ul><li>R/O PE </li></ul>
  41. 43. Echocardiogram <ul><li>Spherical LV </li></ul><ul><li>Mitral and Tricuspid regurgitation </li></ul><ul><li>Left Atrial enlargement </li></ul><ul><li>EF <55% </li></ul>
  42. 44. Case Presentation <ul><li>EKG WNL </li></ul><ul><li>CXR-mild edema </li></ul><ul><li>Echo: </li></ul><ul><ul><li>EF 47% </li></ul></ul><ul><ul><li>Mild Mitral Regurg </li></ul></ul><ul><ul><li>Mild LV dilatation </li></ul></ul><ul><ul><li>Mild LV hypokinesis </li></ul></ul><ul><ul><li>Mild LA dilatation </li></ul></ul>
  43. 45. Treatment <ul><li>Delivery </li></ul><ul><li>Similar to other forms of CHF </li></ul><ul><ul><li>Diuretics </li></ul></ul><ul><ul><li>ß-blockers </li></ul></ul><ul><ul><li>Digoxin </li></ul></ul><ul><ul><li>Anticoagulants </li></ul></ul><ul><li>* Must consider pregnancy class/breast-feeding harm potential! </li></ul>
  44. 46. Pregnancy Drug Class Review <ul><li>Category A: Controlled studies in pregnant women fail to demonstrate a risk to the fetus in the first trimester with no evidence of risk in later trimesters. The possibility of harm appears remote </li></ul><ul><li>Category B : Presumed safety based on animal studies, with no controlled studies in pregnant women,   or animal studies have shown an adverse effect that was not confirmed in controlled studies in women in the first trimester and there is no evidence of a risk in later trimesters . </li></ul>
  45. 47. Drug class cont….. <ul><li>Category C:   Studies in women and animals are not available  or  studies in animals have revealed adverse effects on the fetus and there are no controlled studies in women.  Drugs should be given only if the potential benefits justify the potential risk to the fetus </li></ul><ul><li>Category D: There is positive evidence of human fetal risk (unsafe), however in some cases such as a life-threatening illness the potential risk may be justified if there are no other alternatives </li></ul>
  46. 48. Drug class cont…. <ul><li>Category X: Highly unsafe: risk of use outweighs any potential benefit.  Drugs in this category are contraindicated in women who are or may become pregnant </li></ul>
  47. 49. Drugs <ul><li>Digoxin Class C </li></ul><ul><ul><li>Symptomatic control </li></ul></ul><ul><ul><li>Requires level monitoring </li></ul></ul><ul><ul><li>Therapeutic levels 0.7-1.2 </li></ul></ul>
  48. 50. Diuretics <ul><li>Lasix Class C </li></ul><ul><ul><li>Reserved for cardiac conditions </li></ul></ul><ul><ul><li>Not recommended in PIH </li></ul></ul><ul><ul><li>May decrease placental perfusion </li></ul></ul><ul><li>Thiazide Diuretics </li></ul><ul><ul><li>Reserved for cardiac conditions </li></ul></ul><ul><ul><li>Not recommended in PIH </li></ul></ul><ul><ul><li>Thrombocytopenia has been reported in breast feeding infants </li></ul></ul>
  49. 51. Vasodilators <ul><li>Hydralazine Class C </li></ul><ul><ul><li>Compatible with breastfeeding </li></ul></ul><ul><li>ACE Inhibitors </li></ul><ul><ul><li>Class D in 2 nd /3 rd trimesters </li></ul></ul><ul><ul><li>Reserved for postpartum use-compatible with BF </li></ul></ul><ul><ul><li>Renal toxicity in infants exposed in utero </li></ul></ul>
  50. 52. Beta-Blockers <ul><li>Class C </li></ul><ul><li>Compatible with breast feeding </li></ul><ul><li>Has been shown to cause IUGR in some infants in utero. </li></ul>
  51. 53. Anticoagulants <ul><li>Heparin Class C </li></ul><ul><ul><li>Short half life-can be discontinued prior to delivery to prevent maternal hemorrhage </li></ul></ul><ul><ul><li>Not excreted in breast milk </li></ul></ul><ul><li>Warfarin Class D </li></ul><ul><ul><li>Contraindicated in pregnancy </li></ul></ul><ul><ul><li>Safe in breast feeding. Not excreted in breast milk. </li></ul></ul>
  52. 54. Other Therapy <ul><li>IV Immune Globulin </li></ul><ul><ul><li>One retrospective study </li></ul></ul><ul><ul><ul><li>6 PPCM treated </li></ul></ul></ul><ul><ul><ul><li>11 controls </li></ul></ul></ul><ul><ul><ul><li>All 6 treated had >10 units improvement in EF, compared only 4/11 controls </li></ul></ul></ul><ul><ul><li>( All pts had diagnosis of Myocarditis and dilated cardiomyopathy) </li></ul></ul><ul><ul><li>* McNamara et al. Circulation 1997; 95:2476 </li></ul></ul>
  53. 55. Other Therapy cont…. <ul><li>Cardiac Transplant </li></ul><ul><ul><li>Estimated that transplant is performed in up to 1/3 of PPCM patients </li></ul></ul><ul><ul><li>Pts should be strongly advised against future pregnancies. </li></ul></ul><ul><ul><ul><li>Increased risk of HTN, preeclampsia, and preterm labor </li></ul></ul></ul><ul><ul><ul><li>Also at risk for graft failure due to recurrent disease. </li></ul></ul></ul><ul><ul><ul><li>*Scott et al. Obstet Gynecol 1993; 82:324 </li></ul></ul></ul>
  54. 56. Differential Diagnosis <ul><li>PIH </li></ul><ul><ul><li>However, HF associated with PIH represents a diastolic failure, vs. systolic in PPCM </li></ul></ul><ul><li>Pulmonary Embolism </li></ul><ul><ul><li>Again, usually ruled out by CXR </li></ul></ul><ul><ul><li>If still suspicious, can order spiral CT </li></ul></ul>
  55. 57. Prognosis <ul><li>Mortality estimates range from 25-50%. </li></ul><ul><li>Most deaths occur within 3 months postpartum </li></ul><ul><ul><li>Deaths usually caused by: </li></ul></ul><ul><ul><ul><li>Progressive pump failure </li></ul></ul></ul><ul><ul><ul><li>Arrhythmias </li></ul></ul></ul><ul><ul><ul><li>Thromboembolic events </li></ul></ul></ul>
  56. 58. Prognosis cont… <ul><li>India study </li></ul><ul><ul><li>20 pts. PPCM </li></ul></ul><ul><ul><li>Followed for 14 months postpartum </li></ul></ul><ul><ul><li>Found several factors for deterioration: </li></ul></ul><ul><ul><ul><li>Age >30 </li></ul></ul></ul><ul><ul><ul><li>High Parity </li></ul></ul></ul><ul><ul><ul><li>Later onset of sx. Following pregnancy </li></ul></ul></ul><ul><ul><ul><li>Worse echo findings on initial exam </li></ul></ul></ul><ul><ul><ul><li>* Elkayam et al. N Engl J Med 2001; 344:1567 </li></ul></ul></ul>
  57. 61. Future Pregnancies?? <ul><li>Opinions widely vary </li></ul><ul><li>Most experts agree that patients should avoid future pregnancy if LV dysfunction is persistent greater than 6 months </li></ul>
  58. 62. Literature <ul><li>One study: </li></ul><ul><ul><li>NEJM 2001 – USC </li></ul></ul><ul><ul><ul><li>44 Patients PPCM undergoing subsequent preg. </li></ul></ul></ul><ul><ul><ul><li>28 had normal LV function </li></ul></ul></ul><ul><ul><ul><li>16 had persistent LV dysfunction </li></ul></ul></ul><ul><ul><ul><li>Results: </li></ul></ul></ul><ul><ul><ul><ul><li>Average 10% drop in LVEF in normalized group </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Average 4% drop in LVEF in dysfunctional group </li></ul></ul></ul></ul><ul><ul><ul><ul><li>More than 20% drop in >21% of patients in group 1 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>19% mortality rate in group 2 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>*Elkayam et al. N Engl J Med 2001; 444:1567 </li></ul></ul></ul></ul>
  59. 63. Future Pregnancies cont… <ul><li>Highly Individual </li></ul><ul><ul><li>Patient education of risks </li></ul></ul><ul><ul><li>MFM, Cardiology involvement in decision </li></ul></ul><ul><li>If future pregnancy desired: </li></ul><ul><ul><li>Maternal Echocardiogram per trimester </li></ul></ul><ul><ul><li>Serial sonograms for growth </li></ul></ul><ul><ul><li>Again, Subspecialty involvement </li></ul></ul>
  60. 64. Summary <ul><li>PPCM –Dilated myopathy </li></ul><ul><li>1:3000-4000 pregnancies </li></ul><ul><li>Maternal mortality Increasing! </li></ul><ul><li>36 WGA- 5mo. Postpartum </li></ul><ul><li>Symptoms: </li></ul><ul><ul><li>Dyspnea, Edema, Orthopnea </li></ul></ul><ul><li>EKG, CXR, Echocardiogram </li></ul><ul><ul><li>CBC, CMP, BNP, TSH, etc. </li></ul></ul><ul><li>Tx: Diuretics, B-blockers, ACEI, Anticoagulants </li></ul><ul><li>Consult, consult, consult </li></ul><ul><li>Prognosis varies </li></ul><ul><li>Future Pregnancies…..??? </li></ul>
  61. 65. References <ul><li>Demakis, JG, Rahimtoola, SH, Sutton, GC, et al. Natural course of peripartum cardiomyopathy. Circulation 1971; 44:1053 </li></ul><ul><li>Sanderson, JE, Olsen, EG, Gatei, D. Peripartum heart disease: An endomyocardial biopsy study. Br Heart J 1986; 56:285 </li></ul><ul><li>Midei, MG, DeMent, SH, Feldman, AM, et al. Peripartum myocarditis and cardiomyopathy. Circulation 1990; 81:922 </li></ul><ul><li>O'Connell, JB, Costanzo-Nordin, MR, Subramanian, R, et al. Peripartum cardiomyopathy: Clinical, hemodynamic, histologic and prognostic characteristics. J Am Coll Cardiol 1986; 8:52 </li></ul><ul><li>Rizeq, MN, Rickenbacher, PR, Fowler, MB, et al. Incidence of myocarditis in peripartum cardiomyopathy. Am J Cardiol 1994; 74:474 </li></ul><ul><li>Nelson, JL. Pregnancy, persistent microchimerism, and autoimmune disease. J Am Med Womens Assoc 1998; 53:31 </li></ul><ul><li>Cenac, A, Beaufils, H, Soumana, I, et al. Absence of humoral autoimmunity in peripartum cardiomyopathy. A comparative study in Niger. Int J Cardiol 1990; 26:49 </li></ul>
  62. 66. References cont… <ul><li>Pearl, W. Familial occurrence of peripartum cardiomyopathy. Am Heart J 1995; 129:421 </li></ul><ul><li>McNamara, DM, Rosenblum, WD, Janosko, KM, et al. Intravenous immune globulin in the therapy of myocarditis and acute cardiomyopathy. CIrculation 1997; 95:2476 </li></ul><ul><li>Scott, JR, Wagoner, LE, Olsen, SL, et al. Pregnancy in heart transplant recipients: management and outcome. Obstet Gynecol 1993; 82:324 </li></ul><ul><li>Elkayam, U, Tummala, PP, Rao, K, et al. Maternal and fetal outcomes of subsequent pregnancies in women with peripartum cardiomyopathy. N Engl J Med 2001; 344:1567 </li></ul><ul><li>Pearl,W. Familial Occurrence of peripartum Cardiomyopathy. Am Heart Journal 1995; 129:421-22 </li></ul><ul><li>Sliwa, K, Forster, O, Zhanje, F, et al. Outcome of subsequent pregnancy in patients with documented peripartum cardiomyopathy. Am J Cardiol 2004; 93:1441 </li></ul>
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