Case Report about peripartum cardiomyopathy

1. A.Naesaburi S., MD
Hasna Medika Cirebon Heart Hospital, Cirebon, Indonesia
A Complete Improvement of Left Ventricle Ejection
Fraction in Peripartum Cardiomyopathy: A Case Report

2. INTRODUCTION
Peripartum cardiomypathy (PPCM)
• Heart failure secondary to left ventricular systolic dysfunction
with a LVEF < 45%
• Occurrence towards the end of pregnancy or in the months
following delivery (mostly in the month following delivery)
• No other identifiable cause of heart failure
Bauersachs J, et al. Eur J Hear Fail. 2019
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3. THE
TALES
OF
PPCM
Sliwa K, et al. Eur J Hear Fail. 2021
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4. CASE ILLUSTRATION
33 y.o woman came to cardiac outpatient clinic
• Shortness of breath since week ago
• She can not lying straight on the bed with the complain
increased during activity
• Prior history of giving birth a month ago without history of
hypertension, bleeding nor seizure during pregnancy
• History of previous episode of SOB (-), prior chemotherapy (-)
and familial history (-)
• This was the first pregnancy she had.
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5. CASE ILLUSTRATION
(PHYSICAL EXAM)
VITAL SIGN
• BP : 128/78
• HR : 98 BPM
• RR : 24 TPM
• T : 36.6OC
• SpO2: 96% (room air)
PHYSICAL EXAMINATION
• JVP : 5+2 cmH2O
• Cor : regular S1-S2, gallop S3 (+), murmur (-)
• Lungs : vesicular breathing sound, bibasilar rales (+)
• Abdomen : unremarkable
• Extremity : ankle swollen (+/+)
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6. CASE ILLUSTRATION
(ECG)
Sinus rhythm, QRS rate 97 tpm, normoaxis, normal P wave, PR interval 140ms, QRS duration 80ms, ST- T
changes (-), LVH (-), RVH (-), fragmented QRS (+), QTc: 458 ms, PVC (+) RV origin.
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7. CASE ILLUSTRATION
(WORKUP)
• EF 33% (Teich)
• Global hypokinetic
• LVH eccentric hypertrophy
with diastolic dysfunction
due to restrictive
impairment
• Mild MR due to functional
• Mild TR, low probability PH
• Good RV contractility
CXR NT Pro BNP
• Unavailable.
• Other laboratory exam also
can not be done due to
financial problem.
Echocardiography
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8. CASE ILLUSTRATION
(WORKUP)
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9. MANAGEMENT
Admit to hospital ward  decline
Furosemide 40 mg bid for two days --
> followed by 40 mg od
Bromocriptine 2.5 mg bid (for 7 days)
Warfarin 3 mg od
Ramipril 1.25 mg bid
Spironolactone 25 mg od
Bisoprolol 1.25 mg od (start
tomorrow)
Stop Breasfeeding
1ST Visite
Bisoprolol and Ramipril
doses were up-titrated at
every monthly visit (if
possible)
Furosemide dose
decreased to 20 mg od,
then down titrated prn
based on clinical condition
Monthly Visite
Patient was asymptomatic
and plan to underwent
echocardiography
evaluation
6th Months
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10. ECHOCARDIOGRAPHY EVALUATION
Echocardiography evaluation revealed an improved LVEF of 62% and decreased left ventricular end-
diastolic diameter (LVEDD)
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11. ECHOCARDIOGRAPHY EVALUATION
Echocardiography evaluation revealed an improved LVEF of 62% and decreased left ventricular end-
diastolic diameter (LVEDD)
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12. DISCUSSION
European Society of Cardiology (ESC)
Guideline 2018 recommends a similar
management as other types of heart failure
(HF) disease, with consideration of whether
the setting is ante- or postpartum
Regitz-Zagrosek, V., et al, 2018. Eur Heart J
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13. DIAGNOSIS
Regitz-Zagrosek, V., et al. Eur Heart J. 2018
Bauersachs J, et al. Eur J Hear Fail. 2019
We suggest the patient
had a PPCM based on the
anamnesis, physical
exam and diagnostic
workup, even we can not
performed the NT Pro
BNP examination as a
Position Statement for
HFA of ESC besides
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14. MANAGEMENT
This patient was in a mild PPCM
condition. We suggest to admit her
for further examination, but she
declined.
This situation wasn’t ideal, because
we need to evaluating the
congestion and clinical condition to
initiate or up titrate dose of HF
drugs.
We also suggest the patient to stop
lactating to enables safe treatment
with all established heart failure
drugs
Bauersachs J, et al. Eur J Hear Fail. 2019
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15. MEDICATION
We administrated double dose
furosemide for 2 days and also
initiate ramipril and spironolactone
since day 1.
We also gave bromocriptine
followed by warfarin to enhanced
the cardiac and clinical improvement
without increased risk of
thromboembolism.
Bauersachs J, et al. Eur J Hear Fail. 2019
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16. EVALUATION
Echocardiography evaluation might be done 6-12 months since starting
medication
Following complete recovery, how long medical therapy should continue
is unknown.
All patients with PPCM remain on long-term therapy to avoid
the potential decline in cardiac function
Drugs can be gradually withdrawn under careful surveillance
with serial cardiac imaging and biomarker measurement
Bauersachs J, et al. Eur J Hear Fail. 2019
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17. CONCLUSION
PPCM is a rare condition with unknown etiology requiring the
appropriate management and routine follow up to improve the
clinical condition and fully recovered left ventricle ejection fraction.
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18. THANK YOU
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20. The ‘multiple hit’
model of peripartum
cardiomyopathy
(PPCM)
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23. Disease specific therapy with bromocritine
Hilfiker-Kleiner, et al, Eropean Heart Journal (2017) 38, 2671-2679
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24. • Optimal HF medications combined with bromocriptine and warfarin is mandatory to enhance the
improvement of patient’s clinical condition.
• Bromocriptin  a semisynthetic ergot alkaloid that is a potent agonist of the transmembrane G-protein-
coupled dopamine 2D-receptor and various serotonin receptors in the central nervous system.
• Multicentre randomized (Hilfiker-Kleiner, et al, 2017)  Bromocriptine treatment was associated with high
rate of full LV-recovery and low morbidity and mortality in PPCM patients compared with other PPCM
cohorts not treated with bromocriptine. No significant differences were observed between 1W and 8W
treatment suggesting that 1-week addition of bromocriptine to standard heart failure treatment is already
beneficial with a trend for better full-recovery in the 8W group.
• the importance of anticoagulation (at least prophylactic heparinisation) during bromocriptine treatment
should be emphasized. Anticoagulant was given because Venous embolism occurred in two patients and
peripheral artery occlusion was diagnosed in another patient, all of them treated with the short-term regime
(Koenig, T. et al,. 2018)
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