Management of Postpartum Cardiac Complications
Postpartum cardiac complications require specialized multidisciplinary care through dedicated postpartum hypertension clinics or cardio-obstetrics programs to optimize outcomes and reduce morbidity and mortality. 1
Postpartum Hypertension Management
Blood Pressure Monitoring
- First week postpartum: Check BP daily or twice daily (highest risk period)
- BP peaks 3-7 days postpartum (highest risk for maternal stroke)
- American College of Obstetricians and Gynecologists recommends BP check within 72 hours and again within 10 days of delivery 1
- Home BP monitoring protocols:
- Daily or twice daily in first week after discharge
- Some programs recommend BP monitoring 5 days/week in first week, with decreasing frequency over 6 weeks
- Beyond 6 weeks, monitoring may decrease to twice weekly for up to 1 year postpartum 1
Postpartum Hypertension Clinics
- Provide specialized care through single specialty or multidisciplinary teams
- Key services include:
- Home BP monitoring with active medication titration
- Cardiovascular risk factor screening and management
- Patient education on lifestyle modifications
- Debriefing of delivery and postpartum period
- Assessment of contraception and mental health needs
- Ordering appropriate cardiovascular imaging and stress testing 1
Peripartum Cardiomyopathy Management
Peripartum cardiomyopathy is an idiopathic cardiomyopathy presenting with heart failure due to left ventricular systolic dysfunction (LVEF <45%) towards the end of pregnancy or in the months following delivery 1.
Acute Management
- Administer furosemide (20-40mg IV) to prevent pulmonary edema, especially after delivery when auto-transfusion increases preload 2
- Carefully monitor fluid status to prevent overload 2
- For hemodynamically unstable ventricular tachycardia, immediate cardioversion is recommended 1
- Consider non-invasive cardiac output monitoring to guide management 3
Medication Management
- Antepartum limitations: Avoid renin-angiotensin system blockers and mineralocorticoid receptor antagonists (fetotoxic)
- Acceptable medications:
- Hydralazine/nitrates
- Beta-blockers
- Diuretics (if congestion present)
- Postpartum considerations:
Advanced Therapy
- For cardiogenic shock, consider temporary circulatory support
- Delay implantable cardioverter-defibrillator placement due to high rates of cardiac function recovery 1
Arrhythmia Management
Ventricular Tachycardia
- Acute treatment of hemodynamically unstable VT: immediate cardioversion
- For stable monomorphic VT:
- IV sotalol or procainamide (if available)
- IV amiodarone for hemodynamically unstable VT refractory to conversion
- Prophylactic therapy with cardioselective beta-blockers (e.g., metoprolol)
- Consider ICD implantation for therapy-resistant VT 1
Bradyarrhythmias
- Usually have favorable outcomes without underlying heart disease
- For symptomatic bradycardia:
- Position mother in left lateral decubitus position
- Consider temporary pacemaker for persistent symptoms 1
Special Considerations
Mechanical Heart Valves
- Anticoagulation management is critical
- Switch from oral anticoagulants to LMWH/UFH from 36th week
- Switch to IV UFH at least 36 hours before delivery
- Discontinue UFH 4-6 hours before planned delivery
- Restart 4-6 hours after delivery if no bleeding complications 1
Pulmonary Hypertension
- Associated with 16-30% mortality
- Requires management in specialized pulmonary hypertension center
- Close monitoring in first 4 weeks postpartum (when most deaths occur) 1
Delivery Considerations for Cardiac Patients
- Vaginal delivery with assisted second stage preferred for most cardiac conditions
- Cesarean delivery indicated for:
- Severe aortic stenosis
- Severe pulmonary hypertension
- Acute heart failure
- Mechanical heart valves (may be considered) 1
- Anesthesia: Lumbar epidural analgesia recommended to reduce sympathetic activity
- Avoid methylergonovine due to risk of vasoconstriction and hypertension (>10%) 1, 4
- Use slow IV oxytocin (<2 U/min) after placental delivery to prevent hemorrhage 1
Postpartum Monitoring
- Continue hemodynamic monitoring for at least 24 hours after delivery 1
- Implement early ambulation and elastic support stockings to reduce thromboembolic risk
- Ensure close follow-up with cardiology for women with PPCM, even after recovery 5
Early recognition and prompt multidisciplinary management are essential to improve outcomes in women with postpartum cardiac complications, with specialized postpartum cardiac clinics providing the optimal setting for comprehensive care.