This document discusses peripartum cardiomyopathy (PPCM), a type of dilated cardiomyopathy of unknown etiology that occurs near the end of pregnancy or early in the postpartum period. It defines the diagnostic criteria for PPCM. The incidence varies by geography, with higher rates in South Africa and Nigeria. Risk factors include malnutrition and local customs in the postpartum period. While the etiology is unknown, the pathophysiology is likely similar to other forms of dilated cardiomyopathy. Early diagnosis is important for improving outcomes. Management is multidisciplinary, involving heart failure therapies, delivery planning, contraception counseling, and long term monitoring as maternal and fetal complications can be severe without treatment.

1. Professor of OB/GYN
Benha University
2019
Dr/ Ahmed Walid Anwar Morad

2. • Introduction.
• What is PPCM?
• Incidence
• Risk factors
• Etiology
• Diagnosis
• Management
• Conclusions.

8. What is Peripartum Cardiomyopathy?
• Type of dilated CM of unknown etiology.
• PPCM has strict diagnostic criteria.

10. • CM meeting criteria 3-4 with earlier presentation
is referred to as pregnancy-associated CM
(PACM).
• Underlying pathophysiology is probably similar to
PPCM.
• PACM Often unrecognized, as symptoms of
normal pregnancy commonly mimic those of mild
heart failure.

11. Incidence
• Geography:
– USA → 1 : 4000 live births
– South Africa → 1 : 1000 live births
– Nigeria: higher incidence due to malnutrition and local
customs in the puerperium
• Timing:
– 60% within the first 2 months postpartum
– Up to 7% in the last trimester of pregnancy.

12. Risk factors of PPCM

13. Etiology
The European Society of Cardiology classifies
PPCM as a nonfamilial, nongenetic, idiopathic form
of dilated CM.
However

15. Diagnosis of
PPCM

17. Differential diagnosis of PPCM
PPCM is a diagnosis of exclusion.

19. Complications of Peripartum
Cardiomyopathy

20. Maternal complications
• Arrhythmia (atrial and ventricular).
• Congestive Heart Failure.
• Thromboembolism.
• Sudden death/cardiac arrest/ventricular
arrhythmias

21. Fetal complications
• Fetal ( Distress, IUGR, IUFD) due to:
• Maternal hypoxia
• Placental hypoperfusion
• Preterm labor (spontaneous or indicated)
• Complications of:
• Instrumental delivery
• Anethesia
• Medications for HF (e.g., ACI & Digoxin)
• Psychological

25. Pre-delivery
• Give:
– Diuretics: if symptomatic
– Anticoagulant (Heparin)
– Β blockers if euvolaemic
– Hydralazine & nitrate if BP elevated
• Avoid:
– ACE inhibitors and angiotensin receptor blockers
– Mineralocorticoid receptor antagonists and ivabradine
• Monitor: cardiac imaging and biomarkers
• Delivery plan:

26. Delivery plan
• Timing: Early delivery is not required if fetal and
maternal conditions are stable
• Mode:
– VD is preferred in PPCM with compensated HF
– Avoid Aorto-caval compression
– Shorten 2nd
stage (Instrumental D)
– LSCS:
• Obstetric indications
• Critically ill patient need inotropes

27. Uterotonic drugs
• Used cautiously… Why?
– Oxytocin can cause:
• a marked ↓ in systemic vascular resistance and
• higher doses has an antidiuretic effect
– Ergometrine: significant ↑ in afterload

28. Anesthesia

29. Anticoagulation
• Indications:
– PPCM patients if LVEF is less than 35%.
– When Bromocriptine is used (associated with thromboembolic
events)
• Drugs:
– Antetpartum: low-molecular-weight heparin or unfractionated
heparin
– Postpartum: warfarin may be given.

30. Bromocriptine
• Dose: 2.5 mg twice daily for 2 weeks, followed
by 2.5 mg/day for 6 weeks plus standard HF
therapy.
• Action: pathophysiological approach

31. Pregnancy hormones in peripartum cardiomyopathy

33. Post-delivery
• ICU
• Heart failure:
– Conventional therapy: prolong life and prevent rehospitalization
– Maintain euvolemic volume status
– Follow up
• Anticoagulation therapy
• Counseling regards:
– Contraception
– Brest feeding
• Psychological input.

34. Breast feeding
• Allowed: Controversial and individualized. (Heparin, Warfarin&
Digoxin)
• Avoided:
– Bromocriptine : Potential negative effects of prolactin sub-
fragments (ESC 2010)
– Symptomatic critically ill (ESC guidelines 2b)
– ACE inhibitors in the first few weeks after delivery, particularly in
preterm infants

35. Contraception
• Recommended:
• Progesterone-only coils, implants/ injectables or
progesterone-only pills & barrier methods.
• IUCD
• Sterilization (tubal ligation)
• Not recommended:
• COC: prothrombotic and because they increase fluid
retention, which may exacerbate cardiac disease.

36. Long term management
• Counseling regards subsequent pregnancy
• Persistent sever LV dysfunction (LVEF <35%) :implantable
cardioverter defibrillator ( ICD)
• With myocardial recovery: consider
– Medical therapy withdrawal,
– Monitoring by biomarkers and cardiac imaging every 6 months
– Advise: light exercise (Walking), nutritional supplementation
(Thiamine, Vit D& Iron), contact doctor with common cold and RTI.

37. Risk of PPCM
In Subsequent
Pregnancy
Contraindicated Allowed

39. • Peripartum Cardiomyopathy (PPCM) is a rare
condition with significant mortality.
• PPCM has strict diagnostic criteria.
• Early identification of PPCM improves outcome.

40. • Preconceptual counseling should be offered to
women who have previously suffered from
PPCM.
• Management is multidisciplinary

41. References
• Stergiopoulos K , Fabio V Lima. Peripartum Cardiomyopathy- Diagnosis,
Management, and Long Term Implications, Trends in Cardiovascular
Medicine (2018), doi: 10.1016/j.tcm.2018.07.012
• Jackson AM, Dalzell JR, Walker NL, et al. Peripartum cardiomyopathy:
diagnosis and management. Education in Heart Published Online First:
November 9, 2017]. doi:10.1136/heartjnl-2016-310599
• Elkayam U. Clinical characteristics of peripartum cardiomyopathy in the
United States: diagnosis, prognosis, and management. J Am Coll Cardiol.
2011;58(7):659-70.
• Lima FV, Parikh PB, Zhu J, Yang J, Stergiopoulos K. Association of
cardiomyopathy with adverse cardiac events in pregnant women at the time
of delivery. JACC Heart failure. 2015;3(3):257-66.
• Arany Z, Elkayam U. Peripartum Cardiomyopathy. Circulation.
2016;133(14):1397-409.

42. Thank You