This document discusses peripartum cardiomyopathy (PPCM), defined as heart failure occurring during the last month of pregnancy or up to 5 months postpartum without an identifiable cause. Key points: - Incidence is 0.05-0.06% of pregnancies but higher in some African countries due to postpartum salt consumption. - Risk factors include multiparity, advanced maternal age, twins, preeclampsia, hypertension, and African descent. - Causes are mostly idiopathic but may include viral infection or autoimmune response. - Prognosis is variable with 50-60% recovering by 6 months postpartum but others have persistent or worsening dysfunction. M

1. PERIPARTUM
CARDIOMYOPATHY
(PPCM)
Part -1
Dr Raja Mohammed
Cardiologist, Indira Gandhi Govt Gen Hospital and
PG Ins, Pondicherry, India
Email: drrajamd@gmail.com

2. Definition of PPCM
• PPCM is defined as the heart failure occurring for the first
time in the last month of pregnancy or up to five months of
post partum period.
• Diagnostic criteria includes:
• 1) absence of determinable cause of HF and absence of
existing heart disease
• 2) time period as mentioned above
• 3) echocardiographic evidence of LV dysfunction
demonstrated by reduced EF < 45% or FS < 30%

3. Incidence
• Very less incidence of around 0.05 to 0.06% in all
pregnancies
• In certain countries more common, example in Africa 1 in
300 pregnancies, due to consumption of a salt called
KANWA, a tradition, in post delivery period. It causes fluid
retention and hypertension in most

4. Predisposing factors & cause
The following are considered predisposing factors,
• Multiparous women
• Elderly gravida
• Twin pregnancy
• Pre-eclampsia
• Eclampsia
• Post-partum hypertension
• Certain races like African descent
• Selenium deficiency- doubtful
• Maternal cocaine abuse

5. Causes
• A viral infection in some cases or idiopathic in majority
• genetic and environmental causes cannot be ruled out
• Myocarditis proven in some cases who underwent
endomyocardial biopsy, myocarditis may be due to viral
origin or an immunologic response to a placenta or fetal
antigen
• Maladaptation of hyperdynamic circulation and
remodelling of LV, stress in the LV wall, hypertension
during pregnancy causes exaggerated reduction in LV
function

6. Clinical features
Symptoms:
• Easy fatigue
• Dyspnea on exertion, PND, orthopnea
• Palpitations, non – specific chest discomfort
• Peripheral edema, evidence of fluid overload
• Abdominal discomfort and abdominal distension
• Symptoms of LV failure and RV dysfunction
• Occasionally with findings of thromboembolic phenomenon
Signs:
• Findings of CHF seen, including JV distension, rales, hepatic
congestion and edema

7. Lab investigations
• Pt may show elevated levels TNF α, interleukins,
apoptosis signaling receptors
• CXR- signs of pulmonary venous congestion and usually
cardiomegaly
• ECG- almost always abnormal and may show non-
specific ST T abnormality
• Echocardiography is the diagnostic tool- shows
decreased LV contractility with variable degrees of LV
enlargement, other findings may be left atrial
enlargement, MR, pericardial effusion
• Viral, bacterial and Coxsackie B cultures in some cases
• Endomyocardial biopsy in severe cases and with
suspicion of autoimmune and antigenic cause

8. Prognosis & Advice
• About 50 to 60% completely recover by six months post
partum
• The remaining continue to have stable LV dysfunction or
deteriorate
• Estimated Maternal mortality is between 10 to 50%
• In a data from CDC, 48% died within 42 days of delivery
and 50% between 43 days and 1 year
• Advice :
• Pts of PPCM, recovered and with residual LV dysfunction
and who deteriorated – all should be discouraged to have
subsequent pregnancies, as they develop high
complications

9. Management
• Pts. With heart failure should be treated with oxygen,
diuretics, vasodilators and digitalis if above measures fail.
• Aim is to reduce preload, afterload, increase myocardial
contractility
• Beta blockers are the best choice to control heart failure
in PPCM but ACE inhibitors are the preferred choice for
post partum PPCM
• Dopamine, dobutamine, milrinone like vasopressors are
tried and used successfully at different centres but data
awaited
• ACE inhibitors are contraindicated during pregnancy

10. Management - contd
• Careful hemodynamic monitoring required during labor
and delivery and second stage shortened with the use of
vacuum or forceps
• Fluid overload to be avoided during the entire period
• Anti coagulation is advised once diagnosis is done as
pregnancy itself an hyper coagulable state in addition to
stasis in LV dilation and failure. UHF or LMWH is
preferred before labor and warfarin in post pregnancy
• Immunosuppression in case of proven autoimmune or
antigenic origin after endomyocardial biopsy
• Pts with persistent decompensated HF and with
deteriorating symptoms should be advised transplantation

11. Further reading
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2823141/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696941/
• Textbook of cardiovascular medicine, 3rd edition
• Addendum- next slide: Cardiovascular drugs , safe and
unsafe in pregnancy

12. Medication
Potential side-
effects
Safety in
pregnancy
Safety during breast feeding
ACE inhibitors Embroyopathy Not Yes
AR blocker Embroyopathy Not Yes
B-blockers
Fetal bradycardia/
IUGR
Yes Yes
Hydralizin None Yes Yes
Digoxin Low birth weight Yes Yes
Diuretics
Reduction in
uteroplacental
perfusion
Unclear Yes
Nitrates
Fetal distress with
maternal
hypotension
Yes No data
Lidocain
Fetal CNS
depression
Yes Yes
Procainamide
Maternal
osteoporosis
Yes Yes
LMWH Hemorrhage Yes Yes
Heparin
Hemorrhage/mater
nal
osteoporosis/throm
bocytopenia
Yes Yes
Warfarin
Warfarin
embroyopathy
Yes after 12 weeks Yes
Adenosine Non reported Yes No data