This document defines peripartum cardiomyopathy and discusses its incidence, risk factors, etiology, clinical features, diagnosis, and management. Peripartum cardiomyopathy is defined as heart failure that develops during the last month of pregnancy or within 5 months postpartum without an identifiable cause. It has an incidence of 1 in 2500-4000 live births in the USA and 1 in 300 in Haiti. Risk factors include multi-parity, advanced age, malnutrition, pre-eclampsia, and obesity. Echocardiography is used to diagnose reduced left ventricular ejection fraction. Management involves standard heart failure therapies along with anticoagulation and contraception counseling. Prognosis shows recovery rates of left ventricular function range from

1. Dr.Muhammad Zaid Iqbal 1

2. PERIPARTUM
CARDIOMYO
PATHY
By
Dr. Muhammad Zaid Iqbal
Post Graduate Resident FCPS 2 Internal Medicine
Ibn-e-siena Hospital Multan, Pakistan
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3. Learning Objectives
At the end of this session you should be able to
• Define peripartum cardiomyopathy
• Describe the incidence of peripartum cardiomyopathy
• Describe the risk factors of peripartum cardiomyopathy
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4. Learning Objectives Cont.
• Describe the etiology of peripartum cardiomyopathy
• Describe the clinical features of peripartum cardiomyopathy
• Make differential diagnosis
• Describe investigations needed to diagnose peripartum cardiomyopathy
• Describe the management of peripartum cardiomyopathy
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7. Definition of PPCM 1 (NHLBI 1997)
1. The development of heart failure in the
• last month of pregnancy or
• within 5 months post-partum
1. The absence of an identifiable cause of heart failure
2. The absence of recognizable heart disease prior to the last month of
pregnancy
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8. 4. Echocardiographic criteria:
• LV ejection fraction <45%,
• Fractional shortening <30%, or both,
• With or without LV end-diastolic dimension >2.7 cm/m2 body surface area
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9. Definition (ESC 2010) 2
PPCM is an idiopathic cardiomyopathy presenting with heart failure
secondary to left ventricular systolic dysfunction towards the end of
pregnancy or in the months following delivery, where no other cause of
heart failure is found
• It is a diagnosis of exclusion
• The left ventricle may not be dilated but
• The ejection fraction is nearly always reduced below 45%.
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10. Incidence of PPCM
• 1 in 2500–4000 live births in the USA
• 1 in 1000 in South Africa
• 1 in 300 in Haiti
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11. Incidence of PPCM (Local data)
• 3.8/1000 births (Karachi 2012-2013) 3
• 1 per 837 deliveries (Karachi 2003-2007) 4
• 1 per 933 deliveries (Peshawar 2008-2011) 5
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12. Risk Factors (based on local data) 6
• Multi parity
• Advanced age
• Poor socioeconomic class
• Malnutrition
• Smoking
• Tobacco eating
• Pre-eclampsia
• Long term tocolysis
• ? B+ blood group
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13. Risk Factors (cont.)
• Poor antenatal care and late presentation
• Obesity
• Chronic hypertension
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14. Etiology of PPCM
• Many studies have attempted to explain a distinct etiology…but all failed
• Theories
• Myocarditis
• Abnormal immune response
• Genetics
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15. Clinical Features
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16. Differential Diagnosis of PPCM
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17. Differential diagnosis Contd.
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18. Investigations
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19. Investigations Cont.
• Cardiac imaging
• To establish diagnosis
• Rule outVHD
• LV clot
• Prognostic information
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20. Investigations cont.
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21. Investigations
• B-type natriuretic peptide
As a result of elevated LV end-diastolic pressure due to systolic dysfunction
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22. Management of PPCM
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23. Management of PPCM 7
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24. Management cont.
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• Delivery
• Caesarian section…unstable patients
• Vaginal delivery…stable patients

25. Management cont.
• Anticoagulation
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26. Management cont.
• Breastfeeding
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27. Management cont.
• Bromocriptine
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28. Management cont.
• Devices and transplantation
• Implantable cardioverter defibrillator (ICD):
• Not appropriate
• Wearable cardioverter defibrillator (WCD):
• Prevents SCD 3-6 months after diagnosis
• EF< 35% prevents sudden cardiac death
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29. Management cont.
• Transplantation
• Patients who do not recover after 6–12 months
• Patients with PPCM have higher rates of graft
failure and death after heart transplantation
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30. Prognosis (long term mortality)
• 1-6 months postpartum
2 to 12.6%
• 6–12 months postpartum
4–14%
• 1–5 years postpartum
7%
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31. Prognosis
• Recovery of left ventricular function at 6 months (LVEF>45%)
• 46–63% have been reported in Japan, China,Turkey, Germany,USA
• 21–36% in South Africa,Nigeria,Pakistan,Philippine
• Recovery beyond 6 months (LVEF >50%)
• 72%
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32. Counselling
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33. Contraception
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34. References
1. Pearson GD,Veille JC, Rahimtoola S, Hsia J, Oakley CM, Hosenpud JD, Ansari A,
Baughman KL. Peripartum cardiomyopathy: national heart, lung, and blood
institute and office of rare diseases (national institutes of health) workshop
recommendations and review. Jama. 2000 Mar 1;283(9):1183-8.
2. Sliwa, K., Hilfiker‐Kleiner, D., Petrie, M.C., Mebazaa, A., Pieske, B., Buchmann,
E., Regitz‐Zagrosek,V., Schaufelberger, M.,Tavazzi, L.,VanVeldhuisen, D.J. and
Watkins, H., 2010. Current state of knowledge on aetiology, diagnosis,
management, and therapy of peripartum cardiomyopathy: a position statement
from the Heart Failure Association of the European Society of Cardiology
Working Group on peripartum cardiomyopathy. European journal of heart
failure, 12(8), pp.767-778.
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35. References cont.
3. Perveen S, Ainuddin J, Jabbar S, Soomro K, Ali A. Peripartum cardiomyopathy:
Frequency and predictors and indicators of clinical outcome. Age (Years). 2016
Dec 1;20(2):9-1.
4. Hasan JA, Qureshi A, Ramejo BB, Kamran A. Peripartum cardiomyopathy
characteristics and outcome in a tertiary care hospital. JPMA.The Journal of the
Pakistan Medical Association. 2010 May 1;60(5):377.
5. Shah I, Shah ST, Faheem M, Ullah R, Hafizullah M. Peripartum cardiomyopathy:
risk factors, hospital course and prognosis; experiences at Lady Reading
Hospital Peshawar. Pakistan Heart Journal. 2012 Sep 20;45(2).
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36. References cont.
6. AHMED I, MASROOR M, QAMAR R, HASHMI KA, SATTAR A, IMRAN K, KHAN
MH. Risk factors associated with peripartum cardiomyopathy. Pakistan Heart
Journal. 2012 Dec 5;36(1-4).
7. Sliwa K, Petrie MC, Hilfiker‐Kleiner D, Mebazaa A, Jackson A, Johnson MR, van
der Meer P, Mbakwem A, Bauersachs J. Long‐term prognosis, subsequent
pregnancy, contraception and overall management of peripartum
cardiomyopathy: practical guidance paper from the Heart Failure Association of
the European Society of Cardiology Study Group on Peripartum
Cardiomyopathy. European journal of heart failure. 2018 Jun;20(6):951-62.
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