Peripartum Cardiomyopathy .pdf

Breaking the Silence:
Understanding and Coping with
Peripartum Cardiomyopathy
Professor Dr. Md. Toufiqur Rahman
MBBS (DMC), FCPS (Medicine), MD (Cardiology),
FACC, FRCP, FESC, FAHA, FAPSIC, FASE, FSCAI, FAPSC
Professor and Head, Department of Cardiology
Colonel Maleque Medical College, Manikganj.
Vice President, Bangladesh Society of Cardiovascular Intervention (BSCI)
E-mail: drtoufiq1971@yahoo.com; drtoufiq1971@gmail.com

Prof. Dr. Md. Toufiqur Rahman
Professor and Head of The Department of Cardiology
978-984-35-4357-8 978-984-35-4357-8
First Published : June 2023
Published by : Dr. T. Rahman Cardiac
Care Foundation
Printed by : Bersha Pvt. Ltd,
Pearsons Tower (6th Floor)
299, Elephent Road, Dhaka-1205
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Cover Design : Kazi Atik
Price : 400/- (Four Hundred Taka) Only.
ISBN : 978-984-35-4357-8
"A mother's heart weakened by the miracle of birth, postpartum
cardiomyopathy, a silent thief of life."

Preface
Postpartum cardiomyopathy (PPCM) is a type of heart disease that can
develop in the late stages of pregnancy or in the months following
delivery. Although it is a relatively rare condition, PPCM can have serious
consequences for both the mother and the baby. Despite advances in
medical research, the exact causes of PPCM are not fully understood, and
there is still much to learn about how to prevent, diagnose, and treat this
condition.
This book aims to provide a comprehensive overview of PPCM, including
its causes, symptoms, diagnosis, and treatment. It is intended for
healthcare professionals, researchers, and anyone else interested in
learning more about this important topic. The book is organized into
several sections, each of which covers a different aspect of PPCM.
The first section provides an introduction to PPCM, including its
definition, epidemiology, and risk factors. The second section focuses on
the pathophysiology of PPCM, including the role of hormones, genetics,
and micronutrient deficiencies in the development of the condition. The
third section describes the clinical presentation of PPCM, including its
symptoms, diagnosis, and differential diagnosis. The fourth section covers
the management of PPCM, including medical and surgical treatments, as
well as the management of pregnancy and delivery in women with PPCM.
The final section of the book provides an outlook on the future of PPCM
research, including the development of new diagnostic tools, therapies,
and preventive strategies. We hope that this book will contribute to a better
understanding of PPCM and ultimately improve outcomes for women
affected by this condition.
"Her heart, once full of the promise of new life, now weakened
by postpartum cardiomyopathy."

Dedication
Dedicated to the patients who has been suffered from post partum
cardiomyopathy and recovered successfully or may suffer in future
With each beat of their heart,
They felt the love of those who played a part
In helping them fight and heal,
Their journey to recovery becoming so real.
The days were long and the nights were tough,
But they never lost hope, never gave up.
Their strength and courage shining bright,
As they battled on with all their might.
With the support of family and friends,
And the care of medical professionals until the end,
They fought through the pain and the fear,
Until the day when they could finally cheer.
For they had overcome postpartum cardiomyopathy,
A challenge that tested their strength and bravery.
Now they live each day with gratitude and grace,
Appreciating the love that surrounds them in this new space.
Their hearts beat stronger and their spirits lifted,
Their journey may have been difficult, but it was gifted.
For they now hold a deeper understanding,
Of the power of love, hope, and the beauty of life's landing.
In honor of Professor Quazi Deen Mohammad,
Aluminary in the realm of medicine's trove,
Adedicated professor of neurology's domain,
Whose brilliance and passion forever remain.
With expertise vast and knowledge profound,
He has led countless minds to astound,
As director of NINS, a beacon of light,
Guiding students' aspirations with all his might.
Ex-president of BCPS, esteemed and revered,
His leadership and vision always appeared,
To nurture young minds, inspire them to soar,
To excel in their research and strive for more.
In homage to Professor Abul Kalam Azad,
A luminary in the realm of science he had,
An esteemed professor of biochemistry's sphere,
Whose brilliance and passion inspire us here.
With wisdom and knowledge, he paved the way,
As Ex-Director General of Health, leading each day,
Guiding healthcare systems with a steadfast hand,
Improving lives, spreading wellness across the land.
Ex-Director of MIS, a visionary in his stride,
Harnessing technology, transforming the tide,
Innovating solutions to bridge the digital divide,
Empowering healthcare with progress as his guide.

Contents
Section 1 Page No.
Introduction 01
Epidemiology 02
Aetiology of peripartum cardiomyopathy 03
Genetic aspects of PPCM 10
Section 2
Pathophysiology of PPCM 11
Section 3
Clinical presentation of PPCM 15
Differential diagnosis of PPCM 16
ECG findings of PPCM 20
Echocardiography findings of PPCM 20
Role of natriuretic peptides in PPCM 21
Role of chest x-ray in ppcm 22
Role of cardiac MRI in PPCM 22
Role of CT scan in PPCM 23
Role of Coronary Angiogram in PPCM 24
Role of endomyocardial biopsy in PPCM 24
Section 4
Management of acute heart failure in PPCM 25
Role of heart transplant in PPCM 26
Management of chronic heart failure in PPCM 27
Management of delivery in PPCM 28
Management of breast feeding in PPCM 29
Prevention of sudden cardiac death in PPCM 30
Device therapy in PPCM 31
Prognosis of PPCM 31
Counselling of PPCM 32
Section 5
Future Directions for research about PPCM 33
Conclusion 33
Bibliography 34
Abstract 35
Poem of Cardiomyopathy 36

01
Introduction
Peripartum cardiomyopathy (PPCM) is a type of heart disease that occurs in
women during the last month of pregnancy or within the first few months
after delivery. It is characterized by an enlargement of the heart and a
decrease in the heart's ability to pump blood effectively, leading to
symptoms such as shortness of breath, fatigue, chest pain, and swelling in
the legs and ankles.
The exact cause of PPCM is not well understood, but several hypotheses
have been proposed. One theory is that the immune system may play a role
in the development of PPCM, as some women with PPCM have been found
to have high levels of immune cells in their heart tissue. Another theory
suggests that genetic factors may contribute to the development of PPCM,
as some studies have found that women with a family history of heart
disease are more likely to develop the condition. Hormonal factors, such as
changes in estrogen and progesterone levels during pregnancy, may also
play a role in the development of PPCM, as these hormones can affect the
heart's structure and function. Nutritional deficiencies, particularly of
selenium and vitamin D, have also been associated with an increased risk of
PPCM. Finally, hemodynamic factors, such as increased blood volume
during pregnancy and increased pressure on the heart due to the growing
fetus, may contribute to the development of PPCM.
PPCM can have serious consequences for both the mother and the baby.
Maternal complications can include heart failure, pulmonary edema,
arrhythmias, and even death. Fetal complications can include premature
birth, low birth weight, and fetal death. Therefore, early diagnosis and
treatment are critical for improving outcomes.
Treatment options for PPCM depend on the severity of the condition and the
patient's individual circumstances. Medications such as diuretics, beta-blockers,
and ACE inhibitors are commonly used to manage symptoms and improve heart
function. Lifestyle modifications such as reducing salt intake and avoiding
alcohol can also be helpful. In some cases, advanced therapies such as
mechanical circulatory support or heart transplantation may be necessary.
Despite ongoing research, PPCM remains a challenging condition to
manage. Further studies are needed to better understand its underlying
causes and develop more effective treatments. Women who have had PPCM
are at an increased risk of developing the condition again in future
pregnancies, so close monitoring and early intervention are important for
improving outcomes in subsequent pregnancies.

02
Epidemiology
Peripartum cardiomyopathy (PPCM) is a rare but serious complication of
pregnancy that can affect women worldwide. The incidence of PPCM
varies widely, with estimates ranging from 1 in 1,000 to 1 in 15,000 live
births. The incidence also varies depending on the population studied,
with higher rates reported in some African countries such as Nigeria and
Haiti. However, the reasons for these variations are not well understood.
PPCM can occur at any age, but it most commonly affects women who are
in their 30s or 40s and who have multiple pregnancies. Women who have
pre-eclampsia, gestational hypertension, or diabetes are also at increased
risk for developing PPCM. Additionally, there is a higher incidence of
PPCM in women who are African American compared to women of other
races. Other risk factors for PPCM include a history of heart disease,
obesity, smoking, and cocaine use.
The exact cause of PPCM is not well understood, but it is thought to be
related to a combination of factors, including hormonal changes during
pregnancy, immune system changes, and genetic predisposition. During
pregnancy, the body undergoes significant changes that can put stress on
the heart, such as increased blood volume, increased heart rate, and
increased cardiac output. In some women, this stress can cause damage to
the heart muscle, leading to PPCM
PPCM can have serious consequences for both the mother and the baby.
Maternal complications can include heart failure, pulmonary edema,
arrhythmias, and even death. Fetal complications can include premature
birth, low birth weight, and fetal death. Therefore, early diagnosis and
treatment are critical for improving outcomes.
The diagnosis of PPCM is based on symptoms, physical exam, and
imaging studies such as echocardiography. Treatment options for PPCM
depend on the severity of the condition and the patient's individual
circumstances. Medications such as diuretics, beta-blockers, and ACE
inhibitors are commonly used to manage symptoms and improve heart
function. Lifestyle modifications such as reducing salt intake and avoiding
alcohol can also be helpful. In some cases,
advanced therapies such as mechanical circulatory support or heart
transplantation may be necessary.
PPCM is a rare but potentially life-threatening condition that requires
close monitoring and early intervention to improve outcomes for both the
mother and the baby. Women who are at increased risk for developing
PPCM, such as those with pre-eclampsia, gestational hypertension, or
diabetes, should be closely monitored during and after pregnancy. Women
who have had PPCM are at an increased risk of developing the condition
again in future pregnancies, so close monitoring andearly intervention are
important for improving outcomes in subsequent pregnancies

Aetiology of Peripartum Cardiomyopathy
The exact cause of peripartum cardiomyopathy (PPCM) is unknown,
and it is likely multifactorial. Several theories have been proposed to
explain the pathophysiology of PPCM, but none have been proven
definitively. Here are some of the leading hypotheses on the
aetiology of PPCM:
Immunological factors:Immunological factors have been proposed
as a potential cause of peripartum cardiomyopathy (PPCM).
Researchers have suggested that PPCM may be an autoimmune
disease, in which the body's immune system attacks its own tissues,
specifically the heart muscle. Studies have shown that women with
PPCM have higher levels of inflammatory markers and autoantibodies
compared to healthy women, suggesting that the immune system may
play a role in the development of PPCM.
Autoimmune diseases occur when the immune system mistakenly
identifies healthy tissues as foreign invaders and attacks them. In the
case of PPCM, it is thought that the body produces antibodies that
attack the heart muscle, leading to damage and heart failure. These
antibodies may be directed against specific proteins that are found in
the heart muscle, or they may be directed against proteins that are
similar to those found in the heart muscle.
Several studies have investigated the role of autoimmunity in the
development of PPCM. One study found that women with PPCM
had higher levels of autoantibodies directed against specific proteins
found in the heart muscle, such as cardiac myosin and troponin I.
These autoantibodies were not present in healthy women or women
with heart failure due to other causes, suggesting that they may be
specific to PPCM.
Another study found that women with PPCM had higher levels of
inflammatory markers, such as C-reactive protein and tumor
necrosis factor alpha, compared to healthy women. Inflammation is
a common feature of autoimmune diseases, and these findings
suggest that inflammation may play a role in the development of
PPCM.
03

Despite these findings, the exact mechanisms by which
autoimmunity contributes to the development of PPCM are not well
understood. It is possible that other factors, such as hormonal
changes during pregnancy or genetic predisposition, may interact
with immune system dysfunction to cause PPCM.
Immunological factors, specifically autoimmunity, have been
proposed as a potential cause of peripartum cardiomyopathy.
Studies have shown that women with PPCM have higher levels of
inflammatory markers and autoantibodies compared to healthy
women, suggesting that the immune system may play a role in the
development of PPCM. However, further research is needed to
better understand the underlying mechanisms of this association and
to develop more effective treatments for PPCM.
Genetic factors: Genetic mutations have been identified in some
women with peripartum cardiomyopathy (PPCM), suggesting that there
may be a genetic predisposition to the condition. However, the genetic
basis of PPCM is not yet fully understood, and the role of genetics in the
development of PPCM is still an area of active research.
Several studies have suggested that mutations in genes involved in
cardiac function and regulation may be associated with the
development of PPCM. For example, mutations in the gene that
encodes the protein titin, which is important for the elasticity and
contractility of cardiac muscle cells, have been identified in some
women with PPCM. Mutations in other genes that encode proteins
involved in cardiac contraction, ion channel function, and signal
transduction have also been reported in women with PPCM.
In addition to identifying specific genetic mutations, genome-wide
association studies (GWAS) have been conducted to identify
common genetic variants that may be associated with an increased
risk of PPCM. One such study identified several genetic variants
that were associated with an increased risk of PPCM, including
variants in genes involved in cardiac muscle function,
inflammation, and immune function.
While these studies provide important insights into the genetic basis
of PPCM, the exact role of genetics in the development of the
04

condition is not yet fully understood. It is likely that multiple genetic
and environmental factors contribute to the development of PPCM,
and further research is needed to fully understand the complex
interplay between these factors.
In addition to providing insights into the underlying mechanisms of
PPCM, the identification of genetic mutations associated with the
condition may have important clinical implications. For example,
genetic testing may be useful in identifying women who are at
increased risk of developing PPCM and in guiding treatment
decisions. However, further research is needed to determine the
optimal use of genetic testing in the management of PPCM.
Hormonal factors: Hormonal factors, particularly changes in
estrogen and progesterone levels during pregnancy, have been
proposed as potential contributors to the development of peripartum
cardiomyopathy (PPCM). Estrogen and progesterone are known to
have significant effects on cardiovascular function, including
changes in heart rate, blood pressure, and cardiac output.
During pregnancy, estrogen levels increase significantly, reaching
their peak during the third trimester. Estrogen has been shown to
have both beneficial and detrimental effects on cardiovascular
function. On the one hand, estrogen has been shown to have
vasodilatory effects, which can improve blood flow to the heart and
decrease the workload on the heart muscle. Estrogen has also been
shown to have anti-inflammatory effects, which can reduce
inflammation in the heart muscle and potentially prevent the
development of heart failure.
On the other hand, estrogen has been shown to have negative effects
on the heart muscle. Estrogen can cause changes in the structure and
function of the heart muscle, including an increase in the size of
heart cells and a decrease in the contractile function of the heart
muscle. These changes can lead to impaired cardiac function and the
development of heart failure.
Progesterone, another hormone that increases during pregnancy, has
also been shown to have effects on cardiovascular function.
Progesterone has been shown to have vasodilatory effects, which
05

can improve blood flow to the heart and reduce the workload on the
heart muscle. However, progesterone has also been shown to have
negative effects on the heart muscle, including a decrease in the
contractile function of the heart muscle and an increase in the
susceptibility of the heart to stress.
It is thought that the hormonal changes that occur during pregnancy
may interact with other factors, such as genetic predisposition or
immune system dysfunction, to contribute to the development of
PPCM. For example, estrogen and progesterone may interact with
autoantibodies produced by the immune system to cause damage to
the heart muscle. Alternatively, hormonal changes may interact with
genetic factors to disrupt the normal function of the heart muscle
and lead to the development of heart failure.
In summary, hormonal factors, particularly changes in estrogen and
progesterone levels during pregnancy, have been proposed as
potential contributors to the development of peripartum
cardiomyopathy. These hormones can have both beneficial and
detrimental effects on cardiovascular function, and their interaction
with other factors may play a role in the development of PPCM.
However, further research is needed to better understand the
underlying mechanisms of this association and to develop more
effective treatments for PPCM.
Nutritional deficiencies: There is some evidence to suggest that
deficiencies in certain micronutrients, such as selenium,
magnesium, and vitamin D, may be associated with the
development of peripartum cardiomyopathy (PPCM). However, the
evidence for this theory is limited and further research is needed to
fully understand the role of micronutrient deficiencies in PPCM.
Selenium is an essential micronutrient that acts as an antioxidant and
helps to protect cells from oxidative stress. Studies have shown that
selenium deficiency may be associated with an increased risk of heart
disease, including heart failure. Some studies have also suggested
that selenium deficiency may be more common in women with
PPCM compared to healthy pregnant women. However, the evidence
for this association is limited, and more research is needed to fully
understand the role of selenium in the development of PPCM.
06

Magnesium is another essential micronutrient that is involved in
numerous physiological processes, including muscle contraction
and relaxation. Magnesium deficiency has been associated with an
increased risk of heart disease, including heart failure. Some studies
have suggested that magnesium deficiency may be more common in
women with PPCM compared to healthy pregnant women.
However, the evidence for this association is limited, and more
research is needed to fully understand the role of magnesium in the
development of PPCM.
Vitamin D is a fat-soluble vitamin that plays an important role in
bone health and immune function. Vitamin D deficiency is common,
particularly in pregnant women, and has been associated with an
increased risk of heart disease, including heart failure. Some studies
have suggested that vitamin D deficiency may be more common in
women with PPCM compared to healthy pregnant women.
However, the evidence for this association is limited, and more
research is needed to fully understand the role of vitamin D in the
development of PPCM.
Overall, while there is some evidence to suggest that deficiencies in
micronutrients such as selenium, magnesium, and vitamin D may be
associated with the development of PPCM, the evidence is limited
and further research is needed to fully understand the role of
micronutrient deficiencies in PPCM.
Oxidative stress: Oxidative stress is a physiological process that
occurs when there is an imbalance between the production of free
radicals and the ability of the body to detoxify or repair the damage
caused by these free radicals. Free radicals are unstable molecules
that can damage cells and tissues in the body, including the heart
muscle. Antioxidants, on the other hand, are molecules that can
neutralize free radicals and prevent them from causing damage.
Several studies have suggested that oxidative stress may play a role in the
development of peripartum cardiomyopathy (PPCM). During pregnancy,
the body undergoes significant changes, including an increase in the
production of reactive oxygen species (ROS), a type of free radical, which
can lead to oxidative stress. This can damage the heart muscle and impair
its function, potentially contributing to the development of PPCM.
07

In addition, several other factors associated with pregnancy, such as
pre-eclampsia, gestational diabetes, and obesity, have also been
linked to oxidative stress and may increase the risk of developing
PPCM. These conditions are associated with increased levels of
oxidative stress markers, such as malondialdehyde and oxidized
low-density lipoprotein (LDL), as well as decreased levels of
antioxidants such as superoxide dismutase (SOD) and glutathione.
Furthermore, some studies have suggested that genetic factors may
also play a role in the development of oxidative stress and PPCM.
For example, mutations in genes that regulate the production and
detoxification of ROS, such as superoxide dismutase 2 (SOD2),
have been associated with an increased risk of developing PPCM.
Treatment strategies aimed at reducing oxidative stress may have
potential therapeutic benefits for patients with PPCM. Antioxidant
therapy, such as supplementation with vitamins C and E or
coenzyme Q10, has been shown to improve heart function and
reduce oxidative stress in animal models of heart failure. However,
the effectiveness of antioxidant therapy in humans with PPCM
remains uncertain and requires further investigation.
In conclusion, oxidative stress may play a role in the development
of peripartum cardiomyopathy. The increased production of free
radicals and decreased antioxidant levels during pregnancy, as well
as other risk factors associated with pregnancy, may contribute to
the development of oxidative stress and PPCM. Further research is
needed to better understand the underlying mechanisms of this
association and to develop more effective treatments for PPCM.
Hemodynamic factors: During pregnancy, the cardiovascular
system undergoes significant changes to accommodate the
increased demands of the growing fetus. These changes include an
increase in blood volume, cardiac output, and heart rate, as well as a
decrease in systemic vascular resistance. While these adaptations
are essential for maintaining a healthy pregnancy, they can also put
extra strain on the heart muscle and increase the risk of developing
peripartum cardiomyopathy (PPCM).
08

09
The increased blood volume during pregnancy results in an increase
in the amount of blood that the heart must pump with each heartbeat.
This increases the workload on the heart muscle and can lead to
hypertrophy (enlargement) of the heart muscle cells. In some
women, this hypertrophy may progress to PPCM, in which the heart
muscle becomes weakened and is unable to pump blood effectively.
In addition to the increased blood volume, the increase in cardiac
output during pregnancy also places extra demands on the heart.
Cardiac output is the amount of blood that the heart pumps out of the
left ventricle per minute, and it increases significantly during
pregnancy to meet the needs of the developing fetus. This increased
workload can lead to changes in the structure and function of the
heart muscle cells and may contribute to the development of PPCM.
The decrease in systemic vascular resistance during pregnancy also
places additional strain on the heart. Systemic vascular resistance is
the resistance to blood flow in the systemic circulation (the blood
vessels that supply blood to the body's tissues). During pregnancy,
this resistance decreases to increase blood flow to the developing
fetus. However, this also means that the heart must work harder to
maintain blood pressure and circulation to the body's tissues, which
can increase the risk of developing PPCM.
While these changes in the cardiovascular system are essential for
maintaining a healthy pregnancy, they can also increase the risk of
developing PPCM. Women who have underlying cardiovascular
disease or who have had multiple pregnancies may be at increased
risk of developing PPCM due to the cumulative strain on the heart
over time. Close monitoring during pregnancy and in the
postpartum period is essential for early detection and treatment of
PPCM to improve outcomes for both the mother and the baby.
Overall, the aetiology of PPCM is complex and not fully understood.
Further research is needed to better understand the underlying causes
of this condition and develop effective treatment strategies.
"A heart that once bloomed with life, now weakened by the
miracle of birth."

Genetic aspects of PPCM
As previously mentioned, PPCM is a rare but serious complication
of pregnancy that can lead to heart failure and other serious
complications. While the exact cause of PPCM is not fully
understood, there is growing evidence to suggest that genetic factors
may play a role in the development of the condition.
One gene that has been implicated in the development of PPCM is
the TTN gene. This gene provides instructions for making a protein
called titin, which is the largest protein in the human body and is
essential for the proper functioning of heart muscle cells. Mutations
in the TTN gene have been found in up to 25% of women with
PPCM, suggesting that this gene may be a key contributor to the
development of the condition. Specifically, these mutations may
lead to changes in the structure and function of the heart muscle,
making it more susceptible to damage during pregnancy.
Another gene that has been linked to PPCM is the LMNA gene,
which provides instructions for making a protein called lamin A/C.
Lamin A/C is important for maintaining the structure of the heart
muscle cells, and mutations in this gene can lead to weakened heart
muscle function. Studies have shown that mutations in the LMNA
gene are present in a small percentage of women with PPCM,
although the exact prevalence is not yet known.
It is important to note that not all women with PPCM have
identifiable genetic mutations, and other factors such as
environmental or hormonal influences may also play a role. In
addition, the genetic basis of PPCM is likely complex and involves
multiple genes and interactions between genes and environmental
factors. Further research is needed to better understand the genetic
basis of PPCM and develop targeted therapies for affected
individuals and their families. Genetic counseling and testing may
also be important for families affected by PPCM, as identifying a
genetic mutation can help with family planning and screening for
potential complications in family members.
10

Pathophysiology of PPCM
Peripartum cardiomyopathy (PPCM) is a type of heart failure that
occurs in the last month of pregnancy or in the first few months after
delivery. The exact pathophysiology of PPCM is not fully
understood, but several hypotheses have been proposed:
Myocardial inflammation: Autoimmune diseases occur when the
immune system mistakenly attacks the body's own tissues and organs,
resulting in inflammation and damage. Some researchers believe that
PPCM may be an autoimmune disease because studies have shown
that women with PPCM have higher levels of inflammatory markers
and autoantibodies compared to healthy women.
Autoantibodies are antibodies that target a person's own tissues, and
they have been identified in women with PPCM. These
autoantibodies can attack various components of the heart muscle,
such as the sarcomeres, which are the basic contractile units of the
heart muscle cells, and the myosin heavy chain, which is a key
component of the sarcomere. When the autoantibodies bind to these
components, they can cause inflammation and damage to the heart
muscle, leading to decreased cardiac output and heart failure.
In addition to autoantibodies, other immune system components
may also be involved in the development of PPCM. For example,
cytokines, which are proteins that regulate the immune response,
have been found to be elevated in women with PPCM. These
cytokines can stimulate the immune system and contribute to
inflammation and damage to the heart muscle.
The exact mechanism by which the immune system contributes to the
development of PPCM is not fully understood, and more research is
needed to better understand the role of autoimmunity in the condition.
However, the presence of autoantibodies and elevated cytokine levels
in women with PPCM suggests that the immune system may play a
significant role in the development of the condition.
Abnormal angiogenesis: Angiogenesis is the process of new blood
vessel formation from existing ones. This process is important for
the growth and development of organs and tissues, as well as for
tissue repair and regeneration. During pregnancy, there is an
increase in the production of angiogenic factors that promote blood
vessel growth, including vascular endothelial growth factor (VEGF)
11

and placental growth factor (PlGF). These factors are produced by
the placenta and play a crucial role in maintaining the blood supply
to the developing fetus.
In women with PPCM, there may be an imbalance in angiogenic
factors, with decreased levels of pro-angiogenic factors and
increased levels of anti-angiogenic factors. Anti-angiogenic factors,
such as soluble fms-like tyrosine kinase-1 (sFLT-1), are proteins that
inhibit the growth of blood vessels. High levels of sFLT-1 have been
associated with endothelial dysfunction, which can contribute to the
development of cardiovascular disease.
Studies have shown that women with PPCM have lower levels of
VEGF and PlGF compared to healthy pregnant women, and higher
levels of sFLT-1. This suggests that there may be an imbalance in
angiogenic factors that contributes to the development of PPCM.
The decrease in pro-angiogenic factors may lead to abnormal blood
vessel growth, decreased blood supply to the heart muscle, and
myocardial damage, ultimately resulting in heart failure.
The exact mechanisms by which angiogenic factor imbalances
contribute to the development of PPCM are not fully understood,
and further research is needed. However, the identification of these
imbalances may lead to the development of targeted therapies for
PPCM, such as the use of pro-angiogenic factors to promote blood
vessel growth and improve cardiac function.
Genetic factors: Genetic mutations have been identified in some
women with peripartum cardiomyopathy (PPCM), indicating that
there may be a genetic component to the development of the
condition. Several genes have been implicated in the pathogenesis
of PPCM, including the TTN gene and the LMNA gene.
The TTN gene provides instructions for making a protein called
titin, which is the largest known human protein and is essential for
the proper functioning of heart muscle cells. Mutations in the TTN
gene have been found in up to 25% of women with PPCM. These
mutations may affect the structure and function of titin, leading to
abnormalities in the heart muscle and making it more susceptible to
damage during pregnancy.
Mutations in the LMNA gene, which provides instructions for
making a protein called lamin A/C, have also been associated with
PPCM. Lamin A/C is important for maintaining the structure of the
heart muscle cells, and mutations in this gene can lead to weakened
12

heart muscle function. It is estimated that mutations in the LMNA
gene may be responsible for up to 10% of PPCM cases.
Other genes that have been associated with PPCM include the
SCN5A gene, which provides instructions for making a protein
involved in the electrical signaling of the heart, and the PGC-1α
gene, which plays a role in energy metabolism in the heart muscle.
However, not all women with PPCM have identifiable genetic
mutations, and other factors such as environmental or hormonal
influences may also play a role. It is likely that PPCM is a complex
disorder caused by a combination of genetic and environmental
factors, and further research is needed to better understand the
underlying mechanisms and develop targeted therapies for affected
individuals and their families.
Nutritional deficiencies: Micronutrients are essential nutrients that
the body requires in small amounts to maintain normal
physiological functions. Several studies have suggested that
deficiencies in micronutrients such as selenium, magnesium, and
vitamin D may contribute to the development of PPCM.
Selenium is an important mineral that plays a role in antioxidant
defense, thyroid hormone metabolism, and immune function. Studies
have shown that women with PPCM have lower levels of selenium
compared to healthy pregnant women, and selenium supplementation
has been shown to improve heart function in women with PPCM.
Selenium deficiency can impair the function of the heart muscle cells,
leading to myocardial damage and heart failure.
Magnesium is another important micronutrient that is involved in
regulating heart rhythm, blood pressure, and muscle contraction.
Studies have shown that magnesium deficiency is common in
pregnant women and may contribute to the development of PPCM.
Magnesium supplementation has been shown to improve heart
function and reduce the risk of complications in women with PPCM.
Vitamin D is a fat-soluble vitamin that plays a role in maintaining bone
health, immune function, and cardiovascular health. Several studies
have suggested that vitamin D deficiency may be associated with an
increased risk of PPCM. Vitamin D deficiency can impair the function
of the heart muscle cells and contribute to myocardial damage.
Overall, while the evidence linking micronutrient deficiencies to the
development of PPCM is limited, ensuring adequate intake of these
13

essential nutrients during pregnancy may help to reduce the risk of
developing the condition. Women with PPCM may benefit from
supplementation with selenium, magnesium, and vitamin D under
the guidance of a healthcare provider.
Hormonal factors: During pregnancy, the levels of estrogen and
progesterone increase significantly, which can affect the heart muscle
in several ways. Estrogen has been shown to have both beneficial and
detrimental effects on the heart. It can stimulate the growth of blood
vessels and protect against myocardial damage by reducing oxidative
stress and inflammation. However, it can also cause fluid retention
and increase the risk of blood clots, which can increase the workload
on the heart and potentially lead to heart failure.
Progesterone, on the other hand, can cause relaxation of smooth
muscle cells in blood vessels, leading to decreased vascular
resistance and increased blood flow. This can increase the workload
on the heart and cause it to pump harder to maintain adequate
circulation. Progesterone can also cause changes in the electrical
activity of the heart, which can lead to arrhythmias and potentially
contribute to heart failure.
In women with PPCM, these hormonal changes may exacerbate
underlying genetic or environmental factors that make the heart
more susceptible to damage. For example, if a woman has a genetic
mutation that affects the structure or function of the heart, the
hormonal changes during pregnancy may increase the workload on
the heart and exacerbate the underlying defect. Additionally, if a
woman is deficient in micronutrients that are important for
maintaining normal heart function, the hormonal changes during
pregnancy may further deplete these nutrients and contribute to
myocardial damage.
Overall, while the hormonal changes during pregnancy can have
both beneficial and detrimental effects on the heart, in women with
PPCM, they may contribute to myocardial damage and heart failure.
Close monitoring of cardiovascular health during pregnancy and
early intervention in women with PPCM can help to improve
outcomes for both the mother and the baby.
So, the pathophysiology of PPCM is likely multifactorial and not
fully understood. Further research is needed to better understand the
underlying mechanisms of this condition and develop effective
treatment strategies1.
14

Clinical presentation of PPCM
Peripartum cardiomyopathy (PPCM) is a type of heart disease that can
develop in the late stages of pregnancy or in the months following
delivery. The symptoms of PPCM can be similar to those of other types of
heart failure, and may include:
1. Shortness of breath or difficulty breathing, especially during physical
activity or when lying flat
2. Fatigue or weakness
3. Swelling in the legs, ankles, or feet
4. Rapid or irregular heartbeat
5. Chest pain or discomfort
6. Dry cough
7. Difficulty sleeping
The symptoms of PPCM can be similar to those of other types of heart
failure and can vary in severity. Shortness of breath or difficulty breathing
is a common symptom of PPCM and may be especially noticeable during
physical activity or when lying flat. Fatigue or weakness may also be
present, making it difficult to perform everyday tasks or care for a newborn.
Swelling in the legs, ankles, or feet may occur due to fluid buildup in the
body, and rapid or irregular heartbeat may be present. Chest pain or
discomfort may also be a symptom of PPCM, along with a dry cough and
difficulty sleeping.
It is important for women who experience any of these symptoms during or
after pregnancy to seek medical attention promptly. A thorough physical
examination, including a careful evaluation of the heart and lungs, may be
performed, along with an electrocardiogram (ECG) to measure the
electrical activity of the heart and an echocardiogram to evaluate the
structure and function of the heart. Blood tests may also be done to evaluate
heart function and to rule out other possible causes of symptoms, such as
infections or blood clots.
Treatment for PPCM may involve medications to manage symptoms and
improve heart function, such as diuretics to reduce fluid buildup in the
body and beta blockers to regulate the heart rate. In severe cases,
hospitalization and more intensive treatments may be necessary, including
intravenous medications or mechanical support devices to assist the heart.
It is important for women with PPCM to be closely monitored by a
healthcare provider, as the condition can have serious consequences if left
untreated or poorly managed.
In summary, PPCM is a type of heart disease that can develop during or
after pregnancy and can present with a variety of symptoms, including
shortness of breath, fatigue, swelling, rapid or irregular heartbeat, chest
pain, dry cough, and difficulty sleeping. Early diagnosis and treatment are
important to improve outcomes and reduce the risk of complications for
both the mother and the baby.
15

Differential diagnosis of PPCM
Peripartum cardiomyopathy (PPCM) is a type of heart failure that can
develop in the late stages of pregnancy or in the months following delivery.
failure, and differential diagnosis may include:
Dilated cardiomyopathy: It is a type of heart disease characterized by the
enlargement of the heart's main pumping chamber, the left ventricle, as
well as the thinning and weakening of the heart muscle. This makes it
harder for the heart to pump blood effectively to the body, leading to
symptoms of heart failure.
The exact causes of dilated cardiomyopathy are not fully understood, but it
can be caused by a variety of factors, including genetic mutations,
infections, exposure to toxins, and certain medications. It can also be
caused by other underlying health conditions, such as high blood pressure,
coronary artery disease, or diabetes.
Symptoms of dilated cardiomyopathy may include fatigue, shortness of
breath, swelling in the legs or ankles, cough, chest discomfort, and
palpitations. These symptoms may worsen over time, and can eventually
lead to complications such as heart failure, arrhythmias, and blood clots.
Diagnosis of dilated cardiomyopathy typically involves a physical
examination, electrocardiogram (ECG), echocardiogram, and other tests
such as a cardiac MRI or a stress test. Treatment options may include
medications to improve heart function, lifestyle changes such as exercise
and diet modifications, and in some cases, surgical interventions such as
implantation of a pacemaker or defibrillator, or even heart transplant.
Pulmonary embolism:A pulmonary embolism (PE) is a potentially
life-threatening medical condition that occurs when a blood clot, typically
from the deep veins in the legs or pelvis, travels through the bloodstream
and lodges in the pulmonary arteries in the lungs. This blocks the flow of
blood to the lungs, leading to decreased oxygenation of the blood and
potentially causing damage to the lungs and other organs.
Symptoms of a PE can include sudden onset of shortness of breath, chest
pain, coughing up blood, rapid or irregular heartbeat, lightheadedness or
fainting, and leg swelling. These symptoms can be similar to those of
PPCM, making it important to seek medical attention if any of these
symptoms occur. A physical exam, chest X-ray, CT scan, or other imaging
tests may be used to diagnose a PE, and prompt treatment with blood
16

thinners or other medications can help prevent further complications and
improve outcomes.
Valvular heart disease:It is a type of heart condition that affects the valves
in the heart. The heart has four valves that help regulate the flow of blood
through the heart chambers and into the arteries. These valves can become
damaged or diseased, leading to valvular heart disease.
The two main types of valvular heart disease are:
Stenosis: This occurs when the valve opening becomes narrowed, making
it more difficult for blood to flow through the valve. This can cause the
heart to work harder to pump blood, which can lead to heart failure.
Regurgitation: This occurs when the valve does not close properly, allowing
blood to leak back into the heart chamber. This can also cause the heart to
work harder to pump blood, leading to heart failure.
Valvular heart disease can be caused by a variety of factors, including
congenital defects, infections, and age-related wear and tear. Some
common types of valvular heart disease include:
Aortic stenosis: This occurs when the aortic valve becomes narrowed,
restricting blood flow from the heart to the rest of the body.
Mitral regurgitation: This occurs when the mitral valve does not close
properly, allowing blood to leak back into the left atrium of the heart.
Mitral stenosis: This occurs when the mitral valve becomes narrowed,
making it difficult for blood to flow from the left atrium to the left
ventricle.
Tricuspid regurgitation: This occurs when the tricuspid valve does not
close properly, allowing blood to leak back into the right atrium of the
heart.
Treatment for valvular heart disease may include medications to manage
symptoms and prevent complications, as well as surgical interventions
such as valve repair or replacement. Regular monitoring and follow-up
care is important to manage the condition and prevent further
complications.
Myocarditis: It is a condition in which there is inflammation of the heart
muscle, often caused by a viral infection. The inflammation can cause
damage to the heart muscle cells, making it difficult for the heart to pump
blood effectively. The symptoms of myocarditis can be similar to those of
PPCM and may include chest pain or discomfort, fatigue, shortness of
17

breath, rapid or irregular heartbeat, and swelling in the legs or abdomen.
In some cases, there may be no symptoms at all.
Myocarditis can be diagnosed through a physical exam, electrocardiogram
(ECG), echocardiogram, and blood tests. Treatment may involve
medications to manage symptoms, such as pain or swelling, as well as
medications to reduce inflammation and prevent further damage to the
heart muscle. In severe cases, hospitalization may be required for
monitoring and treatment. It is important to seek medical attention if
symptoms of myocarditis or any other type of heart disease develop, as
prompt diagnosis and treatment can improve outcomes.
Pericarditis: It is a condition characterized by inflammation of the
pericardium, which is the sac that surrounds the heart. It can be caused by
a variety of factors, including viral or bacterial infections, autoimmune
disorders, and certain medications. The inflammation can cause chest
pain, which is typically sharp and worsens when lying down or taking
deep breaths. Other symptoms may include difficulty breathing, coughing,
fatigue, and fever.
In some cases, pericarditis can lead to the accumulation of fluid in the
pericardial sac, a condition known as pericardial effusion. This can cause
additional symptoms, such as swelling of the legs or abdomen, shortness of
breath, and a rapid or irregular heartbeat. If the pericardial effusion is severe,
it can lead to a life-threatening condition known as cardiac tamponade, in
which the fluid compresses the heart and impairs its ability to pump blood
effectively.
The diagnosis of pericarditis typically involves a physical examination, an
electrocardiogram (ECG), and blood tests to check for markers of
inflammation. In some cases, additional tests such as imaging studies or a
pericardiocentesis (a procedure to remove fluid from the pericardial sac)
may be necessary. Treatment typically involves medications such as
nonsteroidal anti-inflammatory drugs (NSAIDs) or colchicine to reduce
inflammation and relieve symptoms. In more severe cases, hospitalization
may be necessary to manage complications or perform additional
treatments, such as draining fluid from the pericardial sac.
Hypertension: It is a condition in which the force of blood against the
walls of the arteries is consistently too high. Over time, this can cause
damage to the arteries and the organs they supply, including the heart.
When hypertension is left untreated, it can lead to the development of
heart failure.
18

Hypertension can cause the heart muscle to thicken, making it more
difficult for the heart to pump blood effectively. This can lead to a decrease
in cardiac output and an increase in the workload on the heart. As the heart
works harder to pump blood, it can become enlarged and weakened,
leading to heart failure.
In addition to the direct effects on the heart muscle, hypertension can also
lead to the development of other conditions that contribute to heart failure,
such as coronary artery disease, atherosclerosis, and atrial fibrillation.
These conditions can further damage the heart and reduce its ability to
function properly.
Managing hypertension through lifestyle changes and/or medication can
help to reduce the risk of developing heart failure. It is important to
monitor blood pressure regularly and work with a healthcare provider to
develop a personalized plan for managing hypertension and reducing the
risk of heart failure.
Anemia: It is a condition in which the body lacks enough red blood cells
or hemoglobin, which is an iron-rich protein in red blood cells that carries
oxygen throughout the body. When there are not enough red blood cells or
hemoglobin, the body's tissues and organs do not receive enough oxygen,
leading to fatigue, weakness, shortness of breath, dizziness, and other
symptoms.
Anemia can be caused by a variety of factors, including nutritional
deficiencies (such as iron, vitamin B12, or folate), chronic diseases (such
as kidney disease or cancer), blood loss (such as from heavy menstrual
periods or internal bleeding), and genetic conditions (such as sickle cell
anemia or thalassemia).
In the context of PPCM, anemia may contribute to the symptoms of
fatigue and shortness of breath that are common to both conditions. It is
important to identify and treat anemia in individuals with PPCM, as it can
worsen the overall prognosis and quality of life. Treatment may involve
iron supplementation, blood transfusions, or addressing the underlying
cause of the anemia.
To determine the underlying cause of the symptoms, a healthcare provider
may perform a physical examination, order blood tests, perform an
electrocardiogram (ECG), echocardiogram, or other diagnostic tests.
Accurate diagnosis and treatment are important to improve outcomes and
manage symptoms.
19

20
ECG findings of PPCM
Electrocardiogram (ECG) is a non-invasive test that measures the
electrical activity of the heart. In peripartum cardiomyopathy (PPCM), the
ECG may show certain findings that suggest heart muscle damage or
dysfunction, such as:
1. ST-T wave changes: The ST segment and T wave on the ECG can
become abnormal in PPCM, with ST segment depression and T wave
inversion being the most common findings. These changes are
indicative of myocardial injury or ischemia.
2. QRS complex changes: The QRS complex duration may be prolonged
in PPCM, suggesting impaired ventricular conduction.
3. Arrhythmias: PPCM can cause arrhythmias such as atrial fibrillation
or ventricular tachycardia, which can be detected on the ECG.
4. Low voltage: The amplitude of the QRS complex may be decreased,
indicating decreased ventricular muscle mass.
5. Atrial enlargement: PPCM can cause enlargement of the atria, which
can be seen as increased P wave amplitude on the ECG.
It is important to note that the ECG findings in PPCM may be non-specific
and can overlap with other cardiac conditions. Therefore, other diagnostic
tests such as echocardiography, cardiac MRI, or cardiac catheterization
may be needed to confirm the diagnosis of PPCM.
Echocardiography findings of PPCM
Echocardiography is the most important diagnostic test for peripartum
cardiomyopathy (PPCM) as it provides a detailed assessment of the heart
structure and function. The following are some of the echocardiography
findings that may be observed in PPCM:
1. Left ventricular dysfunction: The most common finding in PPCM is
left ventricular dysfunction, which is characterized by a reduction in
left ventricular ejection fraction (LVEF) and wall motion
abnormalities. The LVEF may be reduced to less than 45%, and the
wall motion abnormalities are typically diffuse and involve the entire
left ventricle.
2. Dilated left ventricle: The left ventricle may be enlarged (dilated) in
PPCM, with increased end-diastolic and end-systolic volumes.

21
Role of natriuretic peptides in PPCM
Natriuretic peptides, including atrial natriuretic peptide (ANP) and brain
natriuretic peptide (BNP), are hormones secreted by the heart in response
to increased pressure or volume overload. In peripartum cardiomyopathy
(PPCM), the levels of these natriuretic peptides are typically elevated,
reflecting the increased strain on the heart.
ANP and BNP are known to have several physiological effects that can benefit
the heart, including vasodilation, diuresis, and natriuresis. By reducing the
volume and pressure in the circulatory system, natriuretic peptides can
improve cardiac function and relieve symptoms of heart failure.
In PPCM, natriuretic peptides may be used as biomarkers to aid in
diagnosis and prognosis. Elevated levels of BNP have been associated
with worse outcomes in PPCM, including higher rates of mortality and
heart transplantation. Additionally, monitoring the levels of natriuretic
peptides during treatment can help healthcare providers determine the
effectiveness of therapy and adjust treatment plans as needed.
Overall, natriuretic peptides play an important role in the pathophysiology
of PPCM and can be useful in both the diagnosis and management of the
condition.
3. Right ventricular dysfunction: In some cases, right ventricular
dysfunction may also be present, with reduced right ventricular
function and dilatation.
4. Mitral regurgitation: PPCM can cause mitral regurgitation, which is
the backflow of blood from the left ventricle to the left atrium due to
incomplete closure of the mitral valve. This can be detected on
echocardiography as a regurgitant jet.
5. Pericardial effusion: In some cases of PPCM, there may be a buildup
of fluid around the heart (pericardial effusion), which can be visualized
on echocardiography.
It is important to note that the echocardiography findings in PPCM may be
similar to those observed in other types of dilated cardiomyopathy.
Therefore, a careful clinical evaluation is necessary to distinguish PPCM
from other cardiac conditions.

22
Role of chest x-ray in PPCM
Chest X-ray is a commonly used diagnostic tool that can aid in the
evaluation of patients with suspected peripartum cardiomyopathy
(PPCM). The chest X-ray can reveal certain findings that suggest heart
failure or other cardiac abnormalities, such as:
1. Cardiomegaly: Enlargement of the heart, which can be seen as an
increase in the cardiothoracic ratio on the chest X-ray.
2. Pulmonary congestion: Accumulation of fluid in the lungs, which can
be seen as increased markings on the chest X-ray.
3. Pleural effusion: Accumulation of fluid in the space between the lungs
and the chest wall, which can be seen as a blunting of the costophrenic
angle on the chest X-ray.
4. Interstitial edema: Swelling of the tissue between the air sacs of the
lungs, which can be seen as thickening of the interstitial markings on
the chest X-ray.
It is important to note that the chest X-ray findings in PPCM may be
non-specific and can overlap with other cardiac or respiratory conditions.
Therefore, other diagnostic tests such as echocardiography, cardiac MRI, or
cardiac catheterization may be needed to confirm the diagnosis of PPCM.
Role of cardiac MRI in PPCM
Cardiac MRI (magnetic resonance imaging) is a non-invasive diagnostic
tool that uses magnetic fields and radio waves to produce detailed images
of the heart. It can be particularly useful in the evaluation of peripartum
cardiomyopathy (PPCM), as it can provide information on the structure
and function of the heart, as well as the presence of any myocardial
damage or inflammation.
Cardiac MRI can help healthcare providers distinguish between different
types of cardiomyopathy and determine the severity of PPCM.
Specifically, it can:
Assess ventricular function: Cardiac MRI can provide accurate
measurements of ventricular volumes, ejection fraction, and wall motion
abnormalities, which can help determine the severity of heart failure and
guide treatment decisions.

23
Role of CT scan in PPCM
While echocardiography and cardiac MRI are the preferred imaging
modalities for evaluating peripartum cardiomyopathy (PPCM), computed
tomography (CT) scans may also be used in certain cases.
CT scans can provide detailed images of the heart and surrounding
structures, allowing healthcare providers to assess the size and function of
the heart, as well as detect any abnormalities in the coronary arteries or
other structures. CT scans can also help rule out other potential causes of
the patient's symptoms, such as pulmonary embolism or aortic dissection.
However, CT scans expose the patient to ionizing radiation, which can
increase the risk of cancer over time. Therefore, CT scans should be used
judiciously and only when necessary, particularly in pregnant or
breastfeeding women who may be more sensitive to radiation.
Overall, while echocardiography and cardiac MRI are the preferred
imaging modalities for PPCM, CT scans may be used in certain cases to
provide additional information and help guide treatment decisions. The
decision to use CT imaging should be made on a case-by-case basis,
taking into account the risks and benefits for each individual patient.
Identify myocardial damage: Cardiac MRI can detect areas of
myocardial damage or scarring, which can indicate the extent of heart
muscle injury and help predict outcomes.
Detect inflammation: In some cases, PPCM may be associated with
inflammation of the heart muscle. Cardiac MRI can detect signs of
inflammation, such as myocardial edema and late gadolinium
enhancement, which can aid in diagnosis and guide treatment.
Overall, cardiac MRI can provide valuable information for the diagnosis
and management of PPCM, and may be recommended in certain cases
where other diagnostic tests have been inconclusive. However, it is not
routinely used in the initial evaluation of PPCM and may not be
appropriate for all patients. The decision to perform a cardiac MRI should
be made on a case-by-case basis by a healthcare provider.

24
Role of Coronary Angiogram in PPCM
Coronary angiography is a procedure that uses X-ray imaging to visualize
the coronary arteries, which supply blood to the heart muscle. While
peripartum cardiomyopathy (PPCM) is typically not caused by blockages
in the coronary arteries, a coronary angiogram may still be performed in
some cases to rule out other potential causes of symptoms, such as a heart
attack or underlying coronary artery disease.
If a healthcare provider suspects that a patient with PPCM may have
blockages in the coronary arteries, they may recommend a coronary
angiogram to evaluate the blood flow through the arteries and identify any
areas of blockage. However, in most cases, other diagnostic tests such as
echocardiography, cardiac MRI, or natriuretic peptide testing are
sufficient to diagnose and manage PPCM.
It is important to note that coronary angiography is an invasive procedure
that carries some risks, including bleeding, infection, and damage to the
blood vessels or organs. Therefore, it is typically reserved for cases in
which there is a clear indication for the procedure and potential benefits
outweigh the risks.
Role of endomyocardial biopsy in PPCM
Endomyocardial biopsy (EMB) is a diagnostic procedure in which a small
sample of heart tissue is removed for analysis. In peripartum
cardiomyopathy (PPCM), EMB may be used to help confirm the diagnosis
and determine the underlying cause of the condition.
The use of EMB in PPCM is controversial, as it is an invasive procedure that
carries risks, including bleeding and damage to the heart tissue. Additionally,
the yield of EMB in PPCM is low, with studies reporting that only a small
percentage of patients with PPCM have positive biopsy findings.
Despite these limitations, EMB may be considered in select cases of
PPCM, particularly if the diagnosis is uncertain or if there is a suspicion of
another underlying cardiac condition. EMB can also be helpful in
identifying the presence of viral myocarditis, which can mimic the clinical
presentation of PPCM.
Overall, the use of EMB in PPCM is a topic of ongoing debate and should
be approached on a case-by-case basis, with careful consideration of the
potential risks and benefits for each individual patient. reference

25
Management of acute heart failure in PPCM
The management of acute heart failure in peripartum cardiomyopathy
(PPCM) typically involves a combination of supportive measures and
specific medical therapies. The goals of treatment include improving
cardiac function, relieving symptoms, and preventing complications.
Supportive measures may include oxygen therapy, diuretics to reduce
fluid overload, and medications to control blood pressure and heart rate. In
severe cases, mechanical ventilation or circulatory support devices such as
intra-aortic balloon pumps may be necessary.
Specific medical therapies for PPCM may include medications such as
angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and
aldosterone antagonists. These medications can help to improve cardiac
function and reduce the risk of complications such as arrhythmias and
thromboembolic events.
In some cases, immunosuppressive therapy may be used to treat PPCM,
especially in cases where there is evidence of an autoimmune component.
Additionally, anticoagulation therapy may be necessary to prevent blood
clots from forming.
In all cases of PPCM, close monitoring is necessary to ensure that the treatment
is effective and to detect any complications that may arise. This may involve
regular physical exams, blood tests, electrocardiograms, echocardiograms, and
other diagnostic tests as needed.
The management of acute heart failure in PPCM can be complex and
should be tailored to the individual patient's needs. A team-based approach
involving obstetricians, cardiologists, and other healthcare providers is
often necessary to provide comprehensive care.
"A heart once filled with life, now struggling to beat, as the
weight of motherhood takes its toll."

26
Role of heart transplant in PPCM
Heart transplant may be considered as a treatment option for patients with
severe and refractory peripartum cardiomyopathy (PPCM) who do not
respond to medical therapy or device therapy. Heart transplantation
involves the surgical replacement of a patient's diseased heart with a
healthy donor heart.
The decision to pursue heart transplantation in PPCM is typically made on
a case-by-case basis by a multidisciplinary team of healthcare providers,
including cardiologists, transplant surgeons, and other specialists. The
patient's age, overall health, and other factors are taken into consideration
when determining whether heart transplantation is appropriate.
While heart transplantation can be a life-saving procedure for some patients
with PPCM, there are risks associated with the surgery and long-term
immunosuppressive therapy required to prevent rejection of the transplant-
ed heart. Additionally, donor hearts may not always be available, and
patients may need to wait months or even years for a suitable donor match.
Overall, heart transplantation is a rare and complex treatment option for
patients with severe and refractory PPCM, and is typically reserved for
those who have exhausted all other treatment options.
Prof.AKM Fazlur Rahman
Dr. Abul Hossen Shahin
Prof. Mir Jamal Uddin Prof. Dr. Prabir Kumar Das
Dr. Asish Dey Dr. Anisul Awal
Esteemed Contributors

27
Management of chronic heart failure in PPCM
Management of chronic heart failure in peripartum cardiomyopathy
(PPCM) typically involves a combination of lifestyle modifications,
medication therapy, and regular monitoring by healthcare providers.
Lifestyle modifications may include dietary changes, such as
reducing salt intake, and regular exercise to improve heart function
and overall health. Quitting smoking and limiting alcohol
consumption can also be beneficial for patients with PPCM.
Medication therapy for chronic heart failure in PPCM may include:
Angiotensin-converting enzyme (ACE) inhibitors or angiotensin
receptor blockers (ARBs) to help relax blood vessels and reduce
blood pressure.
Beta-blockers to reduce heart rate and workload on the heart.
Diuretics to reduce fluid buildup in the body.
Aldosterone antagonists to help prevent fluid retention and reduce
the risk of heart failure hospitalization.
In addition to medication therapy, regular monitoring by healthcare
providers is important for managing chronic heart failure in PPCM.
This may include regular check-ups, blood tests, electrocardiograms
(ECGs), echocardiograms, or other diagnostic tests to monitor heart
function and adjust treatment plans as needed.
For patients with severe and refractory chronic heart failure, device
therapy such as implantable cardioverter-defibrillators (ICDs) or
cardiac resynchronization therapy (CRT) may also be considered.
Overall, management of chronic heart failure in PPCM is aimed at
reducing symptoms, improving quality of life, and preventing
disease progression. A personalized treatment plan should be
developed by a healthcare provider based on each patient's
individual needs and circumstances

28
Management of delivery in PPCM
The management of delivery in peripartum cardiomyopathy
(PPCM) requires careful consideration to minimize the risk of
complications and optimize outcomes for both the mother and the
fetus. The following are some general principles of management:
1. Multidisciplinary care: Patients with PPCM should receive
care from a multidisciplinary team, including obstetricians,
cardiologists, and anesthesiologists, to ensure that all aspects of
care are coordinated and optimized.
2. Timing of delivery: The timing of delivery should be
individualized based on the severity of PPCM and the
gestational age of the fetus. In general, delivery is recommended
after 36 weeks of gestation to reduce the risk of premature
delivery and associated complications.
3. Mode of delivery: Vaginal delivery is usually preferred in patients
with stable PPCM. However, cesarean delivery may be considered
in cases of fetal distress or maternal hemodynamic instability.
4. Anesthesia: The choice of anesthesia should be made on a
case-by-case basis, taking into account the patient's
hemodynamic status and any contraindications to specific types
of anesthesia. Regional anesthesia, such as epidural or spinal
anesthesia, is generally preferred over general anesthesia in
patients with PPCM.
5. Hemodynamic monitoring: Continuous hemodynamic
monitoring, such as invasive arterial blood pressure monitoring
or pulmonary artery catheterization, may be necessary in
patients with severe PPCM to ensure hemodynamic stability
during delivery.
6. Postpartum management: Patients with PPCM require close
monitoring in the postpartum period to detect any worsening of
symptoms or complications. Medications should be adjusted as
needed, and patients may require continued treatment with heart
failure medications and anticoagulation.
Overall, the management of delivery in PPCM requires careful
consideration and individualized care to optimize outcomes for both
the mother and the fetus.

29
Management of breast feeding in PPCM
The management of breastfeeding in peripartum cardiomyopathy
(PPCM) depends on the severity of the disease and the patient's
individual situation. In general, women with mild to moderate
PPCM can usually continue breastfeeding with appropriate
management and monitoring, while those with severe or advanced
disease may need to stop breastfeeding.
Some medications used to treat heart failure, such as beta-blockers
and ACE inhibitors, can pass into breast milk and potentially harm
the infant. In such cases, alternative medications that are safer for
breastfeeding may be prescribed. Women with PPCM who are
breastfeeding should work closely with their healthcare providers to
ensure that their medications are safe and effective for both
themselves and their infants.
It is also important for women with PPCM to maintain good
nutrition and hydration while breastfeeding, as this can help to
support their overall health and recovery. Women with PPCM may
benefit from working with a lactation consultant or other healthcare
professional to ensure that their breastfeeding practices are optimal
and do not exacerbate their heart failure symptoms.
Overall, the management of breastfeeding in PPCM should be
individualized and based on the patient's specific clinical situation,
taking into consideration the potential risks and benefits for both the
mother and the infant.
Dr. Biplob Bhattacharjee Dr. Neena Islam Prof. Dr. Abu Tarek Iqbal

30
Prevention of sudden cardiac death in PPCM
The prevention of sudden cardiac death (SCD) in peripartum
cardiomyopathy (PPCM) involves the identification and
management of patients who are at high risk for SCD.
Risk stratification tools, such as the European Society of Cardiology
(ESC) criteria or the American College of Cardiology (ACC)
criteria, can help identify patients who are at higher risk for SCD.
Patients who meet high-risk criteria may be considered for
implantable cardioverter-defibrillator (ICD) placement, which can
monitor the heart rhythm and deliver an electrical shock if a
life-threatening arrhythmia is detected.
It is important to note that the decision to implant an ICD should be
made on a case-by-case basis, taking into consideration the patient's
individual clinical situation, as well as their personal preferences
and values. Other factors that may influence the decision to implant
an ICD include the patient's age, overall health, and the potential
risks and benefits of the procedure.
In addition to ICD placement, other measures that may help prevent
SCD in PPCM include aggressive management of underlying heart
failure, including appropriate use of medications and other
therapies, as well as regular monitoring and follow-up with a
healthcare provider.
Overall, the prevention of SCD in PPCM is an important aspect of
disease management, and should be approached with a
multidisciplinary team-based approach that considers the individual
needs and preferences of each patient.
Dr. Md. Abdul Muttalib Dr. Md. Ibrahim Chowdhury Dr. Md. Nuruddin Tareq

31
Device therapy in PPCM
Device therapy, such as implantable cardioverter-defibrillators (ICDs) or
cardiac resynchronization therapy (CRT), may be considered in certain
cases of peripartum cardiomyopathy (PPCM) to prevent sudden cardiac
death or to improve heart function. The decision to use device therapy in
PPCM depends on several factors, including the patient's age, severity of
heart failure, and risk of sudden cardiac death.
ICDs may be recommended in patients with PPCM who have evidence of
impaired left ventricular function or other risk factors for sudden cardiac
death, such as a history of ventricular arrhythmias or syncope. CRT may
be considered in patients with PPCM who have evidence of conduction
abnormalities or left bundle branch block, as it can help to improve cardiac
function and reduce heart failure symptoms.
Device therapy in PPCM should be individualized and carefully
considered, as there are risks associated with implanting devices, such as
infection, bleeding, or complications related to device function. Patients
who receive ICDs or CRT should be closely monitored by their healthcare
providers to ensure proper device function and to manage any
complications that may arise.
Overall, the use of device therapy in PPCM is a complex decision that
should be made on a case-by-case basis by a team of healthcare providers,
including cardiologists, electrophysiologists, and other specialists.
Prognosis of PPCM
The prognosis of peripartum cardiomyopathy (PPCM) varies depending
on the severity of the disease and the patient's response to treatment. In
general, women with mild to moderate PPCM who receive appropriate
medical therapy have a good prognosis and can recover completely or
have stable disease with minimal symptoms.
However, women with severe or advanced PPCM who do not respond to
treatment have a poorer prognosis and may develop complications such as
heart failure, arrhythmias, and thromboembolic events. The mortality rate
for severe PPCM has been reported to be as high as 50%.
The long-term prognosis for women with PPCM also depends on their future
pregnancies. Women who have had PPCM have an increased risk of recur-
rence in future pregnancies, and may also be at increased risk for other cardi-
ovascular complications such as hypertension and coronary artery disease.
Overall, the prognosis for women with PPCM is variable and depends on
several factors, including the severity of the disease, response to treat-
ment, and future pregnancies. Women with PPCM require ongoing moni-
toring and follow-up care to ensure optimal management and outcomes.

32
Counselling of PPCM
Counseling is an essential part of the management of peripartum cardio-
myopathy (PPCM) and should be provided to patients and their families.
Counseling may include information about the disease, its prognosis, and
treatment options, as well as emotional support and guidance.
Patients with PPCM may experience a range of emotions, including anxie-
ty, depression, and fear, and may benefit from counseling or psychothera-
py to help them cope with these feelings. Family members and caregivers
may also need counseling and support, as they may be struggling with
their own emotions and concerns about the patient's health.
In addition to emotional support, counseling for patients with PPCM may
also include education about lifestyle changes and strategies to reduce the
risk of future heart problems. This may include guidance on diet and exer-
cise, stress reduction techniques, and medication management.
Counseling about subsequent pregnancy is an important aspect of the manage-
ment of peripartum cardiomyopathy (PPCM). Women with PPCM who wish
to become pregnant again should be counseled about the risks and benefits of
pregnancy, as well as strategies to reduce the risk of complications.
Women with PPCM who become pregnant again may be at increased risk
of recurrence of the disease or other complications, such as heart failure,
arrhythmias, or thromboembolism. The risk of recurrence may be higher
in women with severe or advanced disease, or those who have not fully
recovered from their initial episode of PPCM.
To reduce the risk of complications, women with PPCM who wish to
become pregnant again may benefit from preconception counseling, close
monitoring during pregnancy, and appropriate medical management.
Women with PPCM who become pregnant again should be evaluated by a
multidisciplinary team, including a cardiologist, obstetrician, and other
healthcare providers as needed.
Women with PPCM who do not wish to become pregnant again should be
counseled about the risks of unintended pregnancy and provided with
appropriate contraception options.
Overall, counseling about subsequent pregnancy in women with PPCM
should be individualized and based on the patient's specific clinical situa-
tion, taking into consideration the potential risks and benefits for both the
mother and the fetus. The decision to pursue subsequent pregnancy should
be made in collaboration with the patient's healthcare providers, and
should be based on a thorough assessment of the patient's cardiac function
and overall health.

33
Conclusion
Postpartum cardiomyopathy is a rare but serious condition that can occur
in women during pregnancy or in the months following delivery. The
exact cause of PPCM is not fully understood, but it may be related to a
combination of genetic, hormonal, nutritional, and environmental factors.
failure, and prompt diagnosis and treatment are essential for improving
outcomes for both the mother and the baby. Treatment may involve
medications to manage symptoms and improve heart function, as well as
lifestyle changes such as a heart-healthy diet and regular exercise. While
PPCM can be a life-threatening condition, with proper management and
care, many women are able to recover and return to their normal activities.
Future Directions for research about PPCM
There are several avenues of research that may help to improve the
diagnosis, treatment, and outcomes for women with PPCM.
One area of research is focused on identifying the underlying causes of
PPCM, including genetic and environmental factors. By understanding the
mechanisms that contribute to the development of PPCM, researchers may
be able to develop more targeted treatments and improve overall outcomes
for affected women.
Another area of research is focused on developing new therapies for
PPCM. This includes investigating the use of medications and other
interventions that may help to reduce myocardial inflammation and
improve cardiac function. Stem cell therapy is also being explored as a
potential treatment option for PPCM.
Additionally, efforts are being made to improve the diagnosis and early
detection of PPCM. This includes developing new diagnostic tools and
biomarkers that may help to identify women at risk for developing the
condition, as well as strategies to ensure that affected women receive
timely and appropriate care.
Overall, continued research into the causes, mechanisms, and treatments
of PPCM has the potential to significantly improve outcomes for women
affected by this condition.

34
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mann, E., ... &Bauersachs, J. (2010). Current state of knowledge on aetiology,
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2. Ware, J. S., Li, J., Mazaika, E., Yasso, C. M., DeSouza, T., Cappola, T. P., ... &
McNamara, D. M. (2016). Shared genetic predisposition in peripartum and
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E. V., Burke, S. D., Tudorache, I., Bauersachs, J., del Monte, F., &Hilfiker-Klein-
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LATIONAHA.113.008431

Abstract
Peripartum cardiomyopathy (PPCM) is a rare form of heart disease that
occurs during the last month of pregnancy or in the first few months after
delivery. It is characterized by a weakened and enlarged heart muscle,
which makes it difficult for the heart to pump blood efficiently. PPCM is a
serious condition that can lead to heart failure, arrhythmias, and even
death if left untreated. The exact cause of PPCM is unknown, but it is
believed to be related to the hormonal changes and increased demands on
the heart that occur during pregnancy.
The diagnosis of PPCM is based on clinical symptoms, such as shortness
of breath, fatigue, chest pain, and edema, along with imaging studies, such
as echocardiography. Treatment for PPCM usually involves medications
to improve heart function and supportive care to manage symptoms. These
medications can include beta-blockers, ACE inhibitors, diuretics, and
inotropic agents. In severe cases, advanced treatments such as mechanical
circulatory support or heart transplantation may be necessary.
The prognosis for PPCM varies depending on the severity of the disease
and the presence of underlying comorbidities. However, with early
diagnosis and appropriate treatment, most women with PPCM can recover
completely and go on to lead healthy lives. The recurrence rate of PPCM
in subsequent pregnancies is approximately 20%, and women who have
had PPCM are advised to avoid future pregnancies or undergo careful
monitoring and management during pregnancy.
There are still many unanswered questions about PPCM, including its
exact cause, optimal diagnostic and treatment strategies, and long-term
outcomes. Further research is needed to better understand this complex
and potentially life-threatening condition.
In conclusion, PPCM is a rare but serious form of heart disease that can
occur during or after pregnancy. Early recognition and management of this
condition are critical in preventing complications and improving
outcomes for both the mother and the baby. Future research will continue
to shed light on the pathophysiology and optimal management of PPCM
35
"The silent thief of a mother's heart, postpartum cardiomyopathy
steals in without warning, demanding all and leaving little behind."

Poem of Cardiomyopathy
A mother's heart beats with love untold,
For the life she carried and brought to the world,
But what if her heart should falter and fail,
Postpartum cardiomyopathy, a heart-wrenching tale.
The joy of birth replaced by fear,
As she struggles to breathe and hold her dear,
Her heart weakened by the strain and stress,
Her life forever changed, a heavy burden to address.
But hope still lingers in the dark of night,
As medicine and care work to set things right,
Her heart may heal and beat once more,
Her love for her child undiminished, as before.
To the doctors and nurses, we owe our thanks,
For their skill and care, their tireless ranks,
To the mothers who fight, we offer our praise,
For their courage and strength through darkest days.
May this poem bring light to postpartum cardiomyopathy,
And raise awareness to this heartbreaking pathology.
When a mother gives birth,
It's supposed to be a time of mirth,
But sometimes, the heart can falter,
And postpartum cardiomyopathy can alter.
The heart becomes weak,
The future may seem bleak,
Breathing may be hard,
And the body may feel scarred.
PPCM is rare,
But when it strikes, it's not fair,
The mother needs care,
And loved ones must be there.
36

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(cÖvwß¯’vb: †gwW‡bvfv, gvwjevM / ccyjvi, kvwšÍ bMi)
†gvevBj: 01714908651, 01777751251, 01911660914

About the Author
Professor Dr. Md. Toufiqur Rahman was born
in Chuadanga, Bangladesh. He completed his
secondary and higher secondary education
from Ideal School, Motijheel and Notre Dame
College, Dhaka respectively. Dr. Rahman
then went on to pursue his MBBS degree from
Dhaka Medical College in 1997. He excelled
in his studies and was recognized as one of the
top performers in his class.
Following the completion of his MBBS,
Dr. Rahman underwent training and
academic attachments at several institutions.
He obtained FCPS degree in Internal Medicine in 2003. He also
completed his MD degree in Cardiology at the NICVD, Dhaka,
where he went on to serve as an Assistant Registrar, Assistant
Professor, Associate Professor and eventually, Professor of
Cardiology. He worked in this capacity until March 2018 when he
joined Colonel Malek Medical College in Manikganj as the
Professor and Head of Cardiology. He has since been instrumental
in establishing the department of cardiology at the college and has
played a key role in training young doctors in the field of cardiology.
Dr. Rahman has a long list of qualifications and fellowships,
including FACC, FESC, FAPSC, FAPSIC, FAHA, FRCPE,
FRCPG, FSCAI, FCCP, FACP and FASE. He has also served as the
Editorial Associate of Cardiovascular Journal.
Throughout his career, Dr. Rahman has been involved in various
teaching activities in different medical colleges and post graduate
institutions. He has published numerous research papers in both
national and international journals and has presented at many
conferences and workshops. He is considered an authority in the
field of cardiology and is often invited to deliver lectures and
presentations at medical conferences and symposiums.
Apart from his professional achievements, Dr. Rahman is also
known for his philanthropic work. He is actively involved in various
social initiatives and has played a key role in organizing medical
camps in rural areas.In recognition of his contributions to the field
of medicine, Dr. Rahman has received several awards and
accolades. He continues to inspire and mentor young doctors and is
regarded as a role model by many in the medical fraternity.

From Heartbeat to Healing:
A Comprehensive guide to
Cardiac Rehabilitation
Books are available at:
Medinova Medical Services Ltd. Malibag Branch
Popular Diagnostic Centre, Unit-2, Shantinagar, Dhaka
Rokomari.com
Mobile: 01714-908651, 01777-751251, 01911-660914
Available books of same author
From Stress to Success:
A Guide to Hypertension
Management
Visualizing the Heart: A
Comprehensive Guide to Diagnostic
Tests and Imaging Modalities in
Cardiovascular Medicine
Heart beat Hero:
Manual of basic CPR Techniques for first
responders

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