Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the diagnosis and treatment of peripartum cardiomyopathy
2. Differentiate between peripartum cardiomyopathy and other medical disorders that may appear on the differential diagnosis

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from through , participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

Peripartum cardiomyopathy (PPCM) is defined as heart failure that may develop toward the end of pregnancy or months after delivery without an identifiable cause. While prognosis has improved substantially over the past several years, women with peripartum cardiomyopathy are still at risk for adverse outcomes.

Table of Contents

• Risk Factors
• Identifying Clinical Features
• Appropriate Tests
• Differential Diagnosis
• Management Considerations
• Pregnancy Specific Considerations
• Subsequent Pregnancies

Risk Factors

• Maternal age ≥30 years | African ancestry | Hypertension | Anemia | Substance misuse | Asthma | Autoimmune disease | Preeclampsia or eclampsia | Multiple gestation | Obesity | Thyroid dysfunction | Prolonged tocolysis
• Pathogenesis remains unknown but appears to be underlying background susceptibility with second ‘hit’ (e.g. endocrine factors of pregnancy)
• Note: Preeclampsia and eclampsia are associated with PPCM and may have shared pathophysiology

Identifying Clinical Features

• Pulmonary rales (left-sided congestion)
• Elevated jugular venous pressure (right-sided congestion)
• Symptoms of congestion
  • Dyspnea on exertion
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Lower extremity edema

Appropriate Tests

• EKG: Sinus rhythm | Non-specific ST-segment or T-wave changes
• Chest X-Ray: Pulmonary edema | Enlarged cardiac silhouette
• B-type natriuretic peptide (BNP): Elevated
  • Note: Not elevated in normal pregnancy
• Echocardiography is the most useful diagnostic tool
  • <45% LVEF (diagnostic requirement)
  • Right ventricular dilation (in some cases)
  • Pulmonary hypertension (in some cases)
  • Atrial enlargement (in some cases)
  • Atrioventricular valvular regurgitation (in some cases)

Differential Diagnosis

• Benign dyspnea of pregnancy
  • Normal CXR | Normal echocardiogram
  • Treatment: No work up required
• Asthma
  • Indicated by pulmonary function tests and bronchodilator response | Wheezing
  • Treatment: Bronchodilator therapy
• Pulmonary embolism
  • Sudden onset |Tachycardia | Chest pain | Unremarkable pulmonary exam | DVT on LE imaging or PE on CT chest angiogram
  • Treatment: Anticoagulation
• Amniotic fluid embolism
  • Sudden onset | Circulatory collapse (usually after labor) | Bleeding (from DIC) | Hypotension | Tachypnea | Crackles on exam
  • Treatment: Supportive care
• Preeclampsia  
  • Hypertension | Proteinuria | Usually accompanied by neurologic symptoms (headache, dizziness) | Echocardiogram shows mildly decreased LVEF
  • Treatment: Proceed with delivery | Supportive care

SYNOPSIS:

Most women (50-80%) will make a full recovery (LVEF >50%) within first 6 months. For prognostic purposes, an LVEF ≥30% usually means a full recovery of left ventricular function is likely, while LVEF <30% suggests a slow or incomplete recovery with respect to achieving full ventricular function. Black ancestry is associated with reduced likelihood of recovery. Due to increased recognition and improved treatment, mortality has improved from 30-50% in 1970’s to 1.3-16% in 2000’s.

KEY POINTS:

Management Considerations

• Early consultation with a cardiologist/ MFM
• Sodium restriction may be required
• Symptomatic pulmonary or peripheral edema present
  • Loop diuretic
• If hemodynamics permit
  • Selective β1 receptor blocker: Metoprolol preferred to avoid uterine stimulation via β2 pathway
  • Avoid ACE inhibitors and angiotensin receptor blockers (ARBs) during pregnancy
    • Some of these medications may be used postpartum depending on lactation safety profile
• Digoxin may be used in pregnancy
• LVEF >35% or those on Bromocriptine (see below)
  • Use anticoagulation 
• Cardioversion and defibrillation may be used in emergent settings (safe in pregnancy)
• Bromocriptine therapy
  • Sympatholytic dopamine D2 agonist
  • Experimental only, based on evidence that prolactin may be involved in pathogenesis
  • Associated complications: Lactation and thromboembolic events
  • Consider on an individual basis in severe cases (LVEF <25%) pending larger trials

Pregnancy-Specific Considerations

• Avoid over-diuresis to maintain perfusion of the placenta
• Close monitoring throughout pregnancy and through 6-months post-partum with echocardiograms (clinical scenario may dictate alternate/ more frequent regimen)
  • Each trimester
  • Immediately after delivery
  • 4 weeks postpartum
• Timing of delivery (AHA recommendations)
  • Stable: Per obstetric indications
  • Unstable or maternal extremis: Prompt delivery
• Breastfeeding
  • Some controversy but unless severe LVEF, benefits may outweigh risks

Subsequent Pregnancies

• LVEF prior to next pregnancy is the strongest predictor of outcome
• If LVEF <50%
  • 50% risk of acute heart failure with worsening disease and increased mortality
  • Pregnancy contraindicated without recovery to normal LVEF thus “repeat pregnancy is contraindicated in women with PCCM”
  • Ensure contraception counseling prior to discharge
• Women with normal function prior to subsequent pregnancy are still at increased risk (20%) of worsening cardiac function

Learn More – Primary Sources

BMJ: State of the Art Review: Peripartum cardiomyopathy (2019)

Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association (2016)

Current management of patients with severe acute peripartum cardiomyopathy: practical guidance from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy (2016)

2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy

‘Ten Commandments’ of the 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy

Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association

Locate a Maternal Fetal Medicine Specialist

Maternal Fetal Medicine Specialist Locator-SMFM

Related ObG Topics:

Diagnosing Preeclampsia – Key Definitions and ACOG Guidelines

The CMQCC Toolkit: Venous Thromboembolism and Antepartum Admission (Non-Delivery)

The CMQCC Toolkit: Venous Thromboembolism Prevention and Management at Delivery

CDC Resources: Contraception in Women with Medical Conditions (US MEC)