>> Definition:
Development of HF toward the end of pregnancy (last month) or within 5 months following delivery
LV systolic dysfunction with an LVEF < 45%
>> High incidence of PPCM in Haitian (1:300) and Nigerian (1:100) women
>> High incidence in Nigeria may be related to a local custom of eating Kanwa, a dry lake salt for 40 days after delivery.
>> It has been suggested that the development of PPCM in these patients may be related in part to hypervolemia and hypertension.
>> Risk Factors:
Age greater than 30 years
African descent
Multiple gestation pregnancy
Hx of preeclampsia, eclampsia, or postpartum hypertension
Maternal cocaine abuse
Long-term (>4 weeks) oral tocolytic therapy with β-adrenergic agonists such as Terbutaline
>> Management Considerations:
Women with HF during pregnancy should be treated similarly to other patients with HF.
Diuretics: Both HCTZ and Furosemide are safe during pregnancy and lactation.
β blockers: Although safe during pregnancy, β1-selective blockers are preferred over nonselective β-blockers to avoid anti-tocolytic action induced by β2-receptor blockade.
ACE-I/ARB: Improve survival but are contraindicated in pregnancy.
Also, since they are secreted in breast milk, breastfeeding must be stopped before starting therapy.
In the setting of atrial fibrillation (most common arrhythmia in patients with PPCM):
Rhythm control (all safe during pregnancy): Digoxin, Procainamide, Quinidine.
Refractory atrial fibrillation requires placement of permanent pacemakers and implantable cardioverter-defibrillators.
REMEMBER: Warfarin is teratogenic
>> Prognosis:
Death due to PPCM is usually caused by progressive pump failure, sudden death, or thromboembolic events.
A subset of patients with PPCM will achieve full recovery of LV function (LVEF > 50%).
However, LV dysfunction can re-occur despite initial full recovery.
Women with PPCM and persistent LV dysfunction or LVEF ≤ 25% at diagnosis are at high risk for recurrent PPCM.
The recommendation in this case is to avoid future pregnancies.
Since up to 20 to 60% of women with PPCM have complete recovery of LVEF by 6 months to 5 years, ICD placement should be deferred at least 3 months following presentation.
Patients with PPCM are at high risk for thrombus formation and thromboembolism due to both the hypercoagulable state of pregnancy and stasis of blood due to severe LV dysfunction.
Still, there is no consensus on prophylactic AC.
General recommendation to start AC for EF < 30% or in setting of atrial fibrillation.
Notes regarding contraception:
Estrogen-Progestin contraceptives (e.g., pills, patch, vaginal ring) may increase fluid retention, which may worsen HF.
In general, Estrogen-Progestin contraceptives should be avoided, particularly early after diagnosis and in women with persistent LV dysfunction due to increased risk of thromboembolism.