Important for medical student

1. PERIPARTUM CARDIOMYOPATHY
Dr. Mohammad Yaqoub Bahar
Feb 14, 2024

4. NORMAL CARDIAC FINDINGS
🞭 Raised JVP with prominent pulsation
🞭 Brisk and diffuse apical impulse, may be
shifted lateral and upward
🞭 Loud S1 , S2 with widely split
🞭 Occasional S3
🞭 Aorto and pulmonary flow murmur
🞭 Murmur
🞭 edema

5. ABNORMAL CARDIAC FINDINGS
🞭 Progressive dyspnea
🞭 Chest pain
🞭 Haemoptysis
🞭 Syncope , cyanosis, clubbing
🞭 Systolic murmur grade 3 or above
🞭 Persistant neck vein distension
🞭 Diastolic murmur
🞭 Persistant arrythmia
🞭 Persistant split S2

7. WHAT IS PERIPARTUM CARDIOMYOPATHY

8. INCIDENCE
🞭 Type of dilated cardiomyopathy of unknown origin
🞭 The European Society of Cardiology currently
classifies PPCM as a nonfamilial, nongenetic form
of dilated cardiomyopathy
🞭 One in 4000 live birth in United State
🞭 Less than 0.1 % of pregnancy with comparable
good prognosis than other cardiomyopathy
🞭 Present with LV systolic dysfunction

9. ETIOLOGY
🞭 Precise mechanism poorly defined
🞭 Some proposed etiologies……
1. Viral myocarditis (parvo virus, human herpes virus 6,
EBV,CMV)
2. Abnormal immune response
3. Abnormal haemodynamic response
4. Prolactin (produce 16kda fragment)
5. Apoptosis and inflammation ( TNF-alpha, CRP)
6. Selenium and malnutrition
7. Prolonged tocolytics use ( more than 4 wks)
8. Increase oxidative stress

11. PRESENTING SYMPTOMS…
🞭 Paroxysmal nocturnal dyspnea
🞭 Dyspnoea on exertion
🞭 Orthopnoea
🞭 Chest pain
🞭 Cough
🞭 Palpitation
🞭 Haemoptysis
Most of symptoms are similar to symptoms occur during
late antepartum and post partum period

12. SIGNS……….
🞭 Tachycardia, tachypnoea
🞭 Regular or irregular pulse
🞭 Persistant neck vein distension
🞭 Blood pressure normal or decrease
🞭 Apex beat shifted, thrusting in nature
🞭 S3 and S4 gallop
🞭 Mitral holosystolic murmur
🞭 Bilateral basal crepitation
🞭 Hepatomegaly (if RHF present)

13. WHAT ARE DIFFERENTIAL DIAGNOSIS

14. DIAGNOSIS CONFIRMED AFTER EXCLUSION OF FOLLOWING
DISEASES…….
🞭 Anemia
🞭 Thyroid disease
🞭 septicaemia
🞭 Idiopathic dilated cardiomyopathy
🞭 Accelerated HTN
🞭 Myocardial infarction
🞭 Acute pulmonary embolism
🞭 Severe preeclamsia
🞭 Pulmonary vasculitis
🞭 Previous valvular diseases

16. INVESTIGATIONS

18. ECG

19. ECG

20. ECG

21. CHANGES IN ECG………
🞭 Sinus tachycardia
🞭 Arrythmia ( e.g atrial fibrillation)
🞭 LVH with strain pattern
🞭 Normal or low voltage QRS complex with
inverted T wave
🞭 Nonspecific ST-T wave changes
🞭 Biventricular and biatrial dilatation
🞭 Conduction defect

22. CHEST X-RAY

23. FINDINGS IN X-RAY
🞭 Cardiac shadow is enlarged in transverse
diameter, LV type apex
🞭 Hyperaemic lung field ( due to pul. congestion)
🞭 Oligaemic lung field ( due to severe pulmonary
hypertension)
🞭 Bilateral plueral effusion
🞭 It may be normal x-ray ( due to acute
presentation)
🞭 May give false impression due to heart is
pushed upward and laterally during pregnancy

24. ECHOCARDIOGRAPHY

25. ECHO FINDINGS……
🞭 Reduced LV wall motion is generalized or global
rather than regional
🞭 Dilatation of all chambers (particularly left
ventricle)
🞭 Left ventricular end diastolic dimension exceeds
52mm( normal 36 to 52mm)
🞭 Valvular compromise including moderate to
severe MR and TR
🞭 Reduce ejection fraction ( <45%)
🞭 LV thrombus

26. BIOMARKERS…..
🞭 NT-proBNP ( not specific, but good sensitive)
🞭 CRP (prognosis of disease)
🞭 16-kDa Prolactin
🞭 Interferon-gamma
🞭 Asymmetric Dimethylarginine
🞭 Cathepsin D
🞭 Fas/Apo-1

27. MRI ( MAGNETIC RESONANCE IMAGING)
🞭 Should be avoided in pregnancy
🞭 If needed, then use with considering risk/
benefit ratio

28. MANAGEMENT

34. ANTICOAGULANTS…….
 🞭 Pregnancy itself is hypercoaguable state with decrease
body’s natural
 anticoagulant…..
🞭 So consider anticoagulant following pt…..
🞭 1. LV EF<35%
🞭 2. paroxysmal and persistent AF
🞭 3. documented Mural thrombus
🞭 4. evidence of systemic embolism
Warfarin and heparin both are safe during breast feeding

35. ASSISTED DEVICES
🞭 IABP ( intra-aortic balloon pump)
🞭 ECMO (extracorporeal membrane
oxygenetion)
🞭 Left ventricular assist device
🞭 Biventricular assist device
🞭 Wearable cardioverter defibrillator
🞭 ICD
🞭 CRT

36. REGARDING DELIVERY AND BREAST FEEDING….
🞭 Timing and mode of delivery :- limited data ( need
multidisciplinary approach)
🞭 PPCM with compensated HF: normal vaginal delivery
preferred
🞭 Caesarean is generally reserved for obstretic
indications ( e.g critically ill pt need inotropes support
)
🞭 Epidural anasthesia preferred
🞭 Early delivery not reqiured if maternal and fetal
conditions are stable (2010 ESC)
🞭 Breast feeding should be avoided due to potential
effect of prolactin subfragmentation ( 2010 ESC)

37. DRUG DURING BREAST
FEEDING…….
Should be avoided….
Spironolactone, atenolol, diltiazem, nifedipine
Can be used…….
Heparin, warfarin, all ACE inhibitors ( mainly
captopril, enalapril), betablockers ( except
atenolol), digoxin

38. ADVISE DURING DISCHARGE
🞭 Daily fluid intake 1 to 1.25L
🞭 Avoid heavy work and aerobic exercise
🞭 Permanent contraception
🞭 Nutritional supplementation ( thiamine, other
vitamins, calcitriol, iron)
🞭 Contact with doctor if any features of common cold,
RTI
🞭 If possible light exercise (e.g- walking)
🞭 Breast feeding now discouraged for more
symptomatic pt ( ESC guideline class 2b)

39. FOLLOW UP OF PATIENT…..
🞭 Follow-up echocardiography at rest or low dose
dobutamine stress test after 6 month
🞭 There is actual less data about discontinuation of
drug
🞭 If pt improves then after 6 month gradually tapper
doses of drugs upto 12 month
🞭 Clinical opinion to continue ACE- inhibitor and
beta- blocker upto 2 yrs

40. SUBSEQUENT PREGNANCY

41. PROGNOSIS OF PATIENT
🞭 Good prognosis from others form of dilated
cardiomyopathy
🞭 50% patients - complete recovery
🞭 25% patients – persistant symptoms
🞭 25% patients – develops complication (progrssive
heart failue, arrythmia, thromboembolism
🞭 Mortality- 3% to 9.6%
🞭 Pt with persistent cardiomegaly after six month
mortality rate 85% in 5yrs

42. THANK YOU
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