This document defines peripartum cardiomyopathy (PPCM) as heart failure that occurs for the first time in the last month of pregnancy or within five months after delivery. It discusses the normal and abnormal cardiac findings, diagnostic criteria, incidence and risk factors, signs and symptoms, differential diagnosis, treatment, mode of delivery, prognosis, risk in subsequent pregnancies, length of treatment, and contraception considerations for patients with PPCM. The key points are that PPCM has an incidence of 1 in 4000 pregnancies, presents clinically in the third trimester or postpartum, and has a variable prognosis depending on initial left ventricular ejection fraction and degree of recovery.

1. PERIPARTUM
CARDIOMYOPATHY
DR DEEPANJALI SAINI
JR1-OBG
DR RPGMC,TANDA
MODERATOR-DR KAMAL

2. DEFINITION
•PPCM is defined as the cardiac
failure occuring for the first time
in the last month of pregnancy or
within five months after
delivery.(WILLIAM OBSTETRICS
26th edition)

5. NORMAL CARDIAC FINDINGS
• Raised JVP with prominent pulsation
• Brisk and diffuse apical impulse, shifted upwards and
outwards
• Loud S1, S2 with widely split
• Occasional S3
• Aorto and Pulmonary flow murmur
• Mammary souffle

6. ABNORMAL CARDIAC FINDINGS
• Progressive dyspnea or orthopnea
• Nocturnal cough
• Hemoptysis
• Syncope
• Chest pain
• Cyanosis
• Clubbing
• Persistent neck vein distension
• Systolic murmur grade 3 or above

7. • Diastolic murmur
• Cardiomegaly
• Persistent arrhythmia
• Persistent split S2

8. NYHA FUNCTIONAL
CLASSIFICATION OF CARDIAC
DISEASE
• Class1 – No symptoms or no limitation in ordinary physical
activity
• Class 2- Mild symptoms and slight limitation during ordinary
activity.
• Class3 – Marked limitation in activity due to symptoms even
during less than ordinary activity.
• Class4 –Severe limitations , symptoms even at rest.

9. DIAGNOSTIC CRITERIA
1. Absence of determinable cause of HF and absence of
existing heart disease.
2. HF for the first time in the last month of pregnancy or upto 5
months of post partum period.
3. Echocardiographic evidence of LV dysfunction demonstrated
by reduced EF <45%
• MAINLY A DIAGNOSIS OF EXCLUSION

10. INCIDENCE, RISK FACTORS &
GENERAL POINTS
• 1 IN 4000 pregnancies
• Women >30 yrs, black, multiparous.
• Women with pre eclampsia or HTN,smoker, malnourished.
• Can result in severe CHF
• Clinically present by 3rd trimester
• Close hemodynamic monitoring and early delivery may be
necessary
• Cardiomyopathy may persist even after delivery
• High rate of recurrence so birth control recommended

16. SIGNS AND SYMPTOMS IN PPCM
V/S NORMAL PREGNANCY
NORMAL PREGNANCY
• FATIGUE
• TACHYCARDIA
• DYSPNEA
• PERIPHERAL EDEMA
PPCM
• FATIGUE
• TACHYCARDIA
• DYSPNEA
• PERIPHERAL EDEMA
• CHEST PAIN
• PND/ORTHOPNEA

18. DIFFERENTIAL DIAGNOSIS OF
PERIPARTUM CARDIOMYOPATHY
MYOCARDITIS
PRE EXISTING IDIOPATHIC/FAMILIAL DILATED OR ACQUIRED
CARDIOMYOPATHY
TAKOTSUBO SYNDROME
PREGNANCY ASSOCIATED MYOCARDIAL INFARCTION
PULMONARY EMBOLISM
AMNIOTIC FLUID EMBOLISM
HYPERTENSIVE HEART DISEASE / SEVERE PRE ECLAMPSIA
HYPERTROPHIC CARDIOMYOPATHY
HIV/AIDS CMP
PRE EXISTING/UNKNOWN CHD

19. SUSPECTED ACUTE PPCM
NATRIURETIC
PEPTIDE
(BNP OR NT-PRO
BNP)
ECHOCARDIOGRAPHY
ABNORMAL
VALUES
NORMAL
VALUES
LVEF>4
5%
LVEF<4
5%
ACUTE PPCM
UNLIKELY
ACUTE PPCM LIKELY

20. TREATMENT

21. NORMAL WARD,
AMBULATORY TREATMENT IN
SELECTED PATIENTS POSSIBLE
INTERMEDIATE CARE INTENSIVE CARE
ORAL HF DRUGS DIURETICS I.V DIURETICS I.V
ORAL DIURETICS IN CASE OF
FLUID OVERLOAD
CONSIDER VASORELAXANTS IF
SBP>110 MMHG
MECHANICAL CIRCULATORY
SUPPORT
CONSIDER BROMOCRIPTINE
FOR 1 WEEK
SUPPLEMENTAL O2;NIV IF
NECESSARY
INVASIVE VENTILATION
AVOID
INOTROPES/CATECHOLAMINE
S
INOTROPES/CATECHOLAMINE
S IF NEEDED
CONSIDER BROMOCRIPTINE
FOR 8WEEKS IF LVEF<25%
CONSIDER BROMOCRIPTINE
FOR 8 WEELS,UPTITRATION
DEPENDS ON PROLACTIN
LEVEL
ORAL HEART FAILURE DRUGS ORAL HEART FAILURE DRUGS
AFTER STABILISATION

23. MODE OF DELIVERY

25. PROGNOSIS
• RESULTS OF IPAC study:
• Upto 72% women with PPCM have improvement in LVEF.
• But increased LV remodelling(LVEDD>6cm), black race, initial
LVEF <30% are poor prognostic factors.

26. RISK IN SUBSEQUENT PREGNANCIES IN
PPCM
• PPCM WITH PARTIALLY OR FULLY
RECOVERED LV FUNCTION(LVEF>50%)
• SUBSTANTIAL RISK OF RELAPSE WITH
SUBSEQUENT PREGNANCY
• RISK OF HEART FAILURE/DEATH(<10%)
• USUALLY GOOD FETAL OUTCOME
SPECIFIC MANAGEMENT:-
• PREGNANCY CAN CONTINUE BUT
SOME RISK REMAIN
• BROMOCRIPTINE-CONSIDER
POSTPARTUM
• ADMISSION TO HIGH CARE UNIT
IF IN DECOMPENSATED HEART
FAILURE
• PPCM WITH POORLY RECOVERED LV
FUNCTION (LVEF<50%)
• HIGH RISK OF RELAPSE WITH
SUBSEQUENT PREGNANCY .RISK OF
HEART FAILURE/DEATH (>10%)
• RISK OF PREMATURE DELIVERY
• RISK OF FETAL DEATH
• SPECIFIC MANAGEMENT:-
• SHOULD ADVISE AGAINST
PREGNANCY ESPECIALLY IF
LVEF<30%
• BOARD:-
• Bromocritine-strongly consider
postpartum
• Oral heart failure drugs
• Anticoagulation
• Relaxants-vasodilators
• Diuretics

27. CONTRACEPTION

29. LENGTH OF TREATMENT FOR
PATIENTS WITH PPCM WITH
RECOVERED LVEF
• Treatment is recommended for at least 12 months after
recovery of both the left ventricular EF & dimensions.
• A period of time without medication and with recurrent
echocardiograms is ideal for confirming that the EF does not
deteriorate before a decision regarding a new pregnancy.

30. SOURCES
• WILLIAM’S OBSTETRICS 26TH EDITION
• DC DUTTA -8TH EDITION
• SLIDESHARE-MAGDY ELMASRY
• www.researchgate.net
• Medscape
• www.ncbi.nlm.nih.gov

31. THANK YOU !!