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peripartum/postpartum cardiomyopathy

Etiology: - idiopathic Epidemiology: 1) 3.0% (1979-1984), 7.7% (1991-1997) of pregnancy-related deaths 2) 2% of deaths occur before delivery 48% within 6 weeks after delivery 50% between 6 weeks & 1 year after delivery 3) older mothers more likely to die from peripartum cardiomyopathy 4) blacks at higher risk of death than whites Clinical manifestations: 1) onset of heart failure in last month of pregnancy, or within 5 months of delivery 2) 15% have pre-eclampsia or pregnancy-induced hypertension 3) 5% with pulmonary embolism or embolic stroke 4) commonly recurs with subsequent pregnancies [1 5) may present with fatigue, exertional dyspnea, cough, wheezing Special laboratory: - electrocardiogram] - sinus tachycardia - normal QRS axis & duration - nonspecific ST-T wave abnormalities - transthoracic echocardiography for evidence of heart failure Radiology: - chest X-ray may show costophrenic angle blunting Management: 1) counsel all women to avoid future pregnancy [1] 2) ACE inhibitor or ARB +/- aldosterone antagonist, beta-blocker, diuretic in combination after delivery [1] - prior to delivery, beta-blocker, digoxin, hydralazine, isosorbide dinitrate. & diuretics may be used 3) if history of angioedema due to ACE inhibitor, amlodipine 4) bromocryptine may be of benefit [3] 5) prognosis: - 50% of women show improvement in LV systolic function within 6 months

General

cardiomyopathy pregnancy disorder; obstetric disorder; pregnancy complication

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 18, 19. American College of Physicians, Philadelphia 2006, 2012, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  2. Journal Watch 24(4):33, 2004 - Whitehead SJ et al, Pregnancy-related mortality due to cardiomyopathy: United States, 1991-1997. Obstet Gynecol 102:1326, 2003 PMID: 14662222
  3. Sliwa K, Blauwet L, Tibazarwa K et al Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy: a proof-of-concept pilot study. Circulation. 2010 Apr 6;121(13):1465-73. PMID: 20308616
  4. Sliwa K, Hilfiker-Kleiner D, Petrie MC et al Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail. 2010 Aug;12(8):767-78. PMID: 20675664
  5. Arany Z, Elkayam U. Peripartum Cardiomyopathy. Circulation. 2016 Apr 5;133(14):1397-409. Review. PMID: 27045128
  6. Park K, Bairey Merz CN, Bello NA, et al; American College of Cardiology Cardiovascular Disease in Women Committee and the Cardio-Obstetrics Work Group. Management of women with acquired cardiovascular disease from pre-conception through pregnancy and postpartum: JACC Focus Seminar 3/5. J Am Coll Cardiol. 2021;77:1799-1812. PMID: 33832606