What are the symptoms and treatment of postpartum cardiomyopathy?

Symptoms and Treatment of Postpartum Cardiomyopathy

Postpartum cardiomyopathy (PPCM) presents with heart failure symptoms that are often mistaken for normal postpartum fatigue, requiring prompt recognition and standard heart failure treatment to reduce mortality and improve outcomes. 1

Symptoms of PPCM

PPCM symptoms can mimic normal physiological changes of pregnancy, leading to delayed diagnosis. Key symptoms include:

Common Presenting Symptoms

• Dyspnea (especially on exertion)
• Orthopnea
• Nocturnal dyspnea
• Persistent cough
• Pedal edema
• Fatigue (often mistaken for normal postpartum tiredness) 1

Additional Symptoms

• Abdominal discomfort from hepatic congestion
• Dizziness
• Praecordial pain
• Palpitations
• Postural hypotension (in later stages)
• Hemoptysis and pleuritic chest pain (if pulmonary embolism develops) 1

Physical Signs

• Displaced apical impulse (72% of patients)
• Third heart sound (92% of patients)
• Mitral regurgitation (43% of patients) 1

Timing of Symptom Onset

• Most common: First 4 months after delivery (78% of cases)
• Less common: Last month of pregnancy (9% of cases)
• Some cases: Prior to 1 month before delivery or more than 4 months postpartum (13%) 1

Diagnostic Approach

PPCM is a diagnosis of exclusion requiring thorough investigation:

1. Electrocardiogram (ECG)

   • Often shows abnormalities including LV hypertrophy voltage criteria (66%) and ST-T wave changes (96%) 1

2. Cardiac Biomarkers

   • Elevated B-type natriuretic peptide (BNP) or N-terminal pro-BNP 1

3. Cardiac Imaging

   • Echocardiography: Primary diagnostic tool showing left ventricular dysfunction
   • MRI: More accurate for chamber volumes and ventricular function assessment
   • Poor prognostic indicators: LVEF <30% or LV end-diastolic diameter >60mm 1

Treatment Algorithm

Acute Management

1. Preload Reduction

   • Diuretics for volume overload
   • Careful fluid management to avoid hypotension

2. Afterload Reduction

   • ACE inhibitors (postpartum only)
   • Hydralazine with nitrates (if still pregnant)

3. Improve Cardiac Contractility

   • Beta-blockers (once stabilized)
   • Consider inotropic support in severe cases

Long-term Management

1. Standard Heart Failure Therapy

   • ACE inhibitors/ARBs
   • Beta-blockers
   • Diuretics as needed
   • Aldosterone antagonists in selected cases

2. Anticoagulation

   • Consider in patients with LVEF <35% due to high risk of thromboembolism 1

3. Advanced Therapies for Refractory Cases

   • Mechanical circulatory support
   • Heart transplantation evaluation if no recovery

Important Considerations

Common Pitfalls

• Delayed diagnosis: Symptoms often attributed to normal postpartum fatigue or respiratory conditions 2
• Misdiagnosis: PPCM may be initially misdiagnosed as pneumonia, pulmonary embolism, or asthma 2
• Inadequate follow-up: Recovery can take 6-12 months, requiring ongoing monitoring

Future Pregnancies

• Subsequent pregnancies carry significant risk of PPCM recurrence
• Risk is lower in women with complete recovery of left ventricular function
• Some experts recommend avoiding future pregnancies, especially in women with persistent LV dysfunction 3

Prognosis

• Mortality rates vary from 3-40% depending on geographic location and healthcare access 4
• Complete recovery of cardiac function occurs in approximately 50% of women
• Recovery typically occurs within 6 months of diagnosis

PPCM is a rare but serious emergency that requires prompt recognition and treatment to improve outcomes for both mother and baby.