Peripartum Cardiomyopathy A Review
Peripartum Cardiomyopathy A Review
Peripartum Cardiomyopathy A Review
Peripartum
Cardiomyopathy
A Review
Anirban Bhattacharyya, MD Peripartum cardiomyopathy is idiopathic heart failure occurring in the absence of any de‑
Sukhdeep Singh Basra, MD,
MPH terminable heart disease during the last month of pregnancy or the first 5 months postpar‑
Priyanka Sen, BS tum. The incidence varies worldwide but is high in developing nations; the cause of the
Biswajit Kar, MD disease might be a combination of environmental and genetic factors. Diagnostic echo‑
cardiographic criteria include left ventricular ejection fraction <0.45 or M‑mode fractional
shortening <30% (or both) and end-diastolic dimension >2.7 cm/m2. Electrocardiography,
magnetic resonance imaging, endomyocardial biopsy, and cardiac catheterization aid in
the diagnosis and management of peripartum cardiomyopathy. Cardiac protein assays can
also be useful, as suggested by reports of high levels of NT-proBNP, cardiac troponin,
tumor necrosis factor- α, interleukin-6, interferon- g, and C‑reactive protein in peripartum
Key words: Cardiac output; cardiomyopathy. The prevalence of mutations associated with familial dilated-cardiomyop‑
cardiomyopathies/diagnosis/
epidemiology/etiology/thera‑ athy genes in patients with peripartum cardiomyopathy suggests an overlap in the clinical
py; cardiomyopathy, dilated/ spectrum of these 2 diseases.
physiopathology/prevention Treatment for peripartum cardiomyopathy includes conventional pharmacologic heart-
& control; cardiomyopathy,
failure therapies—principally diuretics, angiotensin-converting enzyme inhibitors, vaso‑
peripartum; heart failure/
diagnosis/etiology/physio‑ dilators, digoxin, β-blockers, anticoagulants, and peripartum cardiomyopathy-targeted
pathology/therapy; lactation/ therapies. Therapeutic decisions are influenced by drug-safety profiles during pregnancy
blood; postpartum period; and lactation. Mechanical support and transplantation might be necessary in severe
pregnancy complications,
cardiovascular/diagnosis/ cases. Targeted therapies (such as intravenous immunoglobulin, pentoxifylline, and bro‑
epidemiology/etiology/ mocriptine) have shown promise in small trials but require further evaluation. Fortunately,
therapy; pregnancy, mul‑ despite a mortality rate of up to 10% and a high risk of relapse in subsequent pregnancies,
tiple; pregnancy trimester,
third; prognosis; puerperal many patients with peripartum cardiomyopathy recover within 3 to 6 months of disease
disorders; ventricular dys‑ onset. (Tex Heart Inst J 2012;39(1):8-16)
function, left
P
Health, The University of
Texas (Dr. Bhattacharyya); eripartum cardiomyopathy is a rare, serious disease of late pregnancy or early
Department of Internal puerperium. In 1971, Demakis and colleagues 1 first defined peripartum car-
Medicine, Baylor College of diomyopathy as idiopathic heart failure (HF) occurring in the absence of any
Medicine (Dr. Basra); Medi‑
cal Student, Baylor College determinable heart disease in the last month of pregnancy or during the first 5 months
of Medicine (Ms Sen); and postpartum. Later, to prevent over-reporting, echocardiographic criteria (Table I) were
Divisions of Cardiology &
Cardiothoracic Surgery (Dr. added to this definition.2
Kar), Texas Heart Institute Peripartum cardiomyopathy is characterized by its rapid clinical course 3 and a prob-
at St. Luke’s Episcopal Hos‑
pital and Baylor College of
ability for spontaneous recovery.4 It is of interest that early and late presentations of
Medicine; Houston, Texas heart failure in pregnancy appear to have similar demographics and outcomes,5 for
77030 this suggests that the same disease process underlies the 2 presentations. This has led
to a call to review the existing definition of peripartum cardiomyopathy to include
Address for reprints: patients who currently do not fit those strict criteria.6
Biswajit Kar, MD, Division
of Cardiology, Texas Heart
Institute at St. Luke’s Epidemiology
Episcopal Hospital and
Baylor College of Medicine,
6720 Bertner Ave., C355M, Data from population-based and single-center studies provide the best available esti-
Houston, TX 77030 mates of the incidence of peripartum cardiomyopathy. The reported incidence fluc-
tuates globally but is higher in developing countries. For example, the incidence in
E-mail: [email protected] Nigeria7 (1%) or Haiti8 (0.33%) surpasses that in more developed countries, such as
South Africa9 (0.1%) or the United States (1:3,000–4,000 deliveries).4 Environmental
© 2012 by the Texas Heart ® and genetic factors, differences in cultural practices, and standards of perinatal care
Institute, Houston may account for this regional disparity.
µg/min.6 Nitroprusside is not recommended because of abnormalities or there is positive evidence of human fetal risk
on the basis of adverse-reaction data from investigational or
the potential for cyanide toxicity.38 marketing experience, and the risks involved in use of the drug
Inotropic Agents. Use of inotropic agents such as do- in pregnant women clearly outweigh potential benefits.
pamine, dobutamine, and milrinone is warranted only
in cases of severe low output, and the patient should be
weaned from them as soon as she is hemodynamically
stable.6 however, 24 patients treated with levosimendan (0.1
Levosimendan reduces pulmonary capillary wedge µg/kg/min) for 24 hours (in addition to conventional
pressure and improves cardiac output of peripartum therapy) showed no improvement.41 Until adequate safe-
cardiomyopathy patients.39,40 In a randomized trial, ty data are available, levosimendan should be avoided
Fas/Apo-1 = Fas/apoptosis antigen 1; IL-6 = interleukin-6; LV = left ventricular; LVEDD = left ventricular end-diastolic diameter;
LVEF = left ventricular ejection fraction; LVESD = left ventricular end-systolic diameter; Pts = patients; TNF-α = tumor necrosis factor-α
*Year in which recruitment began.