Peripartum cardiomyopathy (PPCM) is a rare form of heart failure that occurs during the last month of pregnancy or within the first five months postpartum. It presents significant challenges in diagnosis and treatment due to its overlap with symptoms of normal pregnancy and postpartum changes. This condition varies in incidence across different racial groups and geographical locations, with a notable occurrence in the United States and southern India.

2. Understanding Peripartum
Cardiomyopathy
Peripartum cardiomyopathy (PPCM) is a rare form of heart failure that occurs during the last
month of pregnancy or within the first five months postpartum. It presents significant
challenges in diagnosis and treatment due to its overlap with symptoms of normal
pregnancy and postpartum changes. This condition varies in incidence across different
racial groups and geographical locations, with a notable occurrence in the United States and
southern India.
by shruti rane

3. Incidence and Risk Factors
1K
US Incidence
1 in 1,000 to 1 in 4,000 cases
1374
India Study
1 case per 1374 live births
Risk factors for PPCM include African descent, advanced maternal age, hypertensive
disorders, and multifetal pregnancies. Understanding these factors is crucial for early
detection and prevention strategies.

4. Diagnosis Challenges
1 Continuum of Symptoms
PPCM features often resemble
normal pregnancy and
postpartum events, making
diagnosis difficult.
2 Fatal Complications
Delayed diagnosis and treatment
can lead to high mortality rates.
Diagnosing PPCM requires a careful evaluation to distinguish its symptoms from those of
typical pregnancy, emphasizing the need for awareness and vigilance among healthcare
providers.

5. Emergency Medical
Case: A Pregnant
Woman's Ordeal
A 27-year-old Primigravida faced a life-threatening emergency at 34.5
weeks gestation. This detailed account follows her journey through a
critical medical situation, highlighting the challenges and interventions of
her healthcare team at Sion Hospital in Mumbai.
by shruti rane

6. Initial Presentation and Symptoms
1 Onset of Symptoms
The patient arrived with sudden breathlessness and perspiration, having
suffered these symptoms for 6 to 7 hours. Additionally, she had cough with
expectoration that had started a day earlier.
2 Medical Background
Known to have preeclampsia, she was under treatment with Labetalol 100
mg TDS and Nifedipine 10R BD. Her antenatal care profile was normal, and
she had been previously advised to seek hospital admission for her
hypertension.
3 Examination Findings
Upon examination, her condition was moderate, with a high pulse rate 140
b/m, blood pressure 180/110 mm of Hg, respiratory rate 30/min, and low
oxygen saturation levels 88% on room air, bilateral pedal edema grade 2,
no premonitory symptoms.

7. Diagnostic Investigations
There was no history of chronic hypertensive disorder, congenital cardiac disorder, valvular
dysfunction, carditis, cardiomyopathy, autoimmune disorders, or any other major medical/
surgical disorder. Patient did not have any significant past obstetric history/ family history
suggestive of any predisposing factor and there was no history of any known allergy/
addictions. Antenatal period was uneventful, until the current episode.
Respiratory
Examination
Bilateral coarse
crepitations were noted in
the respiratory
examination, indicating
severe respiratory
distress.
Imaging Results
Chest X-ray revealed an
enlarged heart shadow
and bilateral opacities,
suggestive of pulmonary
oedema.
Echocardiography
Findings
An urgent echocardiogram
showed significantly
reduced ejection fraction
(25-30%) and global left
ventricular hypokinesia,
mild PAH, moderate MR,
mild TR leading to a
diagnosis of peripartum
cardiomyopathy.

8. Emergency Interventions
Initial Treatment
Antihypertensive therapy (NTG drip) and diuretics were administered to
manage the patient's critical blood pressure and fluid overload.
Ventilation Support
Due to deteriorating respiratory function, the patient was placed on non-
invasive CPAP ventilation and later required mechanical ventilation.
Cardiac Arrest
The patient suffered a sudden cardiac arrest, necessitating immediate
resuscitation and intensive cardiopulmonary support.

9. Peripartum Cardiomyopathy
Diagnosis
Diagnosis Confirmation
With no history of chronic heart or
autoimmune disorders, the patient's
heart failure was clinically diagnosed as
peripartum cardiomyopathy.
Exclusion of Other Causes
Other potential causes of
cardiomyopathy were systematically
excluded, confirming the diagnosis
related to the peripartum period.
Management Plan
The multidisciplinary team managed the patient's condition in the intensive cardiac
critical care unit, focusing on both maternal and fetal well-being.

10. Emergency Cesarean Section
1 Decision for
Surgery
Considering the
critical state of the
patient and the fetal
prognosis, an
emergency cesarean
section was
proposed and
performed within 5
hours of admission
under general
2 Delivery
Outcome
The procedure
resulted in the birth
of a female child
weighing 1894
grams, with the
patient's condition
improving
significantly post-
delivery.
3 Postoperative
Care
Following the
cesarean section, the
patient was shifted
back to the ICCU for
continued care and
monitoring.

11. Postoperative Recovery
1 Extubation
The patient was successfully extubated one day after the surgery, and
inotropic support and lasix was tapered gradually indicating a positive turn in
her recovery.
2 Medication Adjustment
Postoperative medications were adjusted, including the introduction of
Bisoprolol 2.5 mg BD, Tab Lasix, Tab Isolazine.
3 Continued Treatment
Additional treatments such as antibiotics, Co-enzyme, and Carnisure were
administered to support the patient's recovery and continued for 3 months
post disxharge.

12. Postoperative Medication Regimen
2.5
Bisoprolol
Bisoprolol was prescribed
twice daily to manage heart
function.
5000
Heparin
Unfractionated Heparin was
administered
postoperatively for
anticoagulation.
3
Months
Isolazine was advised to be
continued for three months
post-discharge to aid in
recovery.

13. Postpartum Period and Discharge
Echocardiography Before Discharge Improved left ventricular ejection fraction
(45%) and mild regurgitations noted.
Postpartum Ward Stay The rest of the postpartum period was
uneventful, with the patient recovering
well in the ward.
Follow-Up Visits Both the patient and the neonate were in
good condition during subsequent follow-
up visits.

14. Diagnostic Criteria
Cardiac failure in late gestation or early postpartum
No other identifiable cause for heart failure
No preexisting heart disease before pregnancy
Echocardiographic evidence of dysfunction
Left ventricular end diastolic dimension >2.7cm/m2
M-mode fractional shortening <30%
LVEF <45 %
The diagnostic criteria for PPCM are specific and must be met to confirm the diagnosis, which
includes echocardiographic features indicative of significant heart dysfunction.

15. Role of Obstetricians
Early Detection
Obstetricians are crucial in early detection during antenatal follow-ups.
Obstetricians play a vital role in the early stages of PPCM diagnosis,
which is essential for initiating timely treatment and improving
outcomes.
Majority of cases are seen in post natal period. Less than 10% are seen
in antenatal period.

16. SYMPTOMS
While the symptoms of PPCM can vary, common signs include excessive
fatigue, shortness of breath, rapid weight gain, and swelling in the
lower limbs.
Other symptoms may include persistent cough, palpitations, and chest pain.
It is important for obstetricians to be vigilant in recognizing these
symptoms during antenatal visits to ensure timely intervention and
management of PPCM.

17. Therapeutic Interventions
Multidisciplinary approach is required. (Obstetrician, Cardiologist and Intensivist.)
Beta-Blockers
Administered cautiously
to manage heart failure
symptoms.
Diuretics
Used in minimal
effective doses to avoid
fetoplacental
insufficiency.
Anticoagulants
Recommended
postpartum when the
ejection fraction is
below 30%.
Management of PPCM involves a range of therapeutic interventions, including medications to
improve heart function and prevent complications.

18. BROMOCRIPTINE
Bromocriptine, Dopamine agonist a medication typically used to treat
Parkinson's disease, has been shown to be effective in reducing the risk
of heart failure and improving outcomes in women with PPCM.
It was contemplated that excess production of prolactin increased the
accumulation of a 16-kDa prolactin fragment, which is antiangiogenic
and plays an important role by negatively impacting myocardial micro-
vascularization.
It works by suppressing the hormone prolactin, which is believed to play a
role in the development of PPCM.

19. Recovery and Prognosis
1
Recovery Definition
Return of LVEF to 50% or a 20%
improvement.
Usually recovers in 3-6 months
or as late as 48 months.
2 Recurrence Risk
Recurrence in subsequent
pregnancies can be as high as
46%.
3
Long-Term Outcomes
25 % patients may develop
chronic heart failure or have a
fatal course.
The recovery from PPCM can be a prolonged process, and the risk of recurrence in future
pregnancies necessitates careful consideration and monitoring.

20. Conclusion
The case of PPCM presented here illustrates the complexity of this
condition and the importance of early identification, referral, and timely
intervention. The successful treatment of this near-miss case was made
possible by a multidisciplinary team, highlighting the criticality of
emergency cesarean section combined with intensive cardiac care and
comprehensive medical management for heart failure. This case
reinforces the significance of a collaborative approach in the management
of PPCM for favorable maternal and fetal outcomes.