How to manage a 19-year-old pregnant patient at 33+1 weeks gestation with a diagnosis of Peripartum Cardiomyopathy (PPCM), severe hypertension, and impaired left ventricular function (Ejection Fraction 35% with global hypokinesia) despite being on Isoket (isosorbide dinitrate) infusion, Lasix (furosemide) 60mg three times a day, Aldomet (methyldopa), and Hydralazine?

Management of Peripartum Cardiomyopathy with Severe Hypertension

This patient requires immediate delivery and aggressive blood pressure control with intravenous nitroglycerine as first-line therapy, followed by optimization of heart failure management. 1

Immediate Management

Blood Pressure Control

• Severe hypertension (SBP >160 mmHg) requires urgent treatment in a monitored setting 1
• First-line agent for this patient with PPCM and pulmonary edema:
  • IV nitroglycerine (starting at 10-20 up to 200 μg/min) 1
  • Target: Decrease mean BP by 15-25% with goal SBP 140-150 mmHg and DBP 90-100 mmHg 1
• Current regimen is insufficient:
  • Isoket (isosorbide dinitrate) infusion should be optimized
  • Consider adding IV labetalol if nitroglycerine alone is insufficient 1, 2

Heart Failure Management

• Continue furosemide 60 mg TDS to manage pulmonary edema
• Monitor for signs of hypoperfusion (cold/clammy skin, acidosis, renal impairment) 1
• Consider inotropic support if signs of low cardiac output persist despite vasodilator therapy 1

Delivery Planning

• Urgent delivery is indicated regardless of gestation due to:

  • Severe hypertension despite multiple antihypertensive medications
  • Heart failure with EF 35% and global hypokinesia
  • Maternal hemodynamic instability 1

• Delivery method:

  • Planned cesarean section is preferred for critically ill patients requiring inotropic therapy or mechanical support 1
  • Coordinate with multidisciplinary team including obstetrics, anesthesia, cardiology, and neonatology 1

Post-Delivery Management

1. Blood pressure control:

   • Target SBP 110-140 mmHg and DBP around 85 mmHg 3
   • Transition to oral medications when stable:
     • ACE inhibitors (enalapril preferred) can be started post-delivery 1
     • Beta-blockers (metoprolol preferred) 1

2. Heart failure management:

   • Anticoagulation should be considered (LVEF <35%) 1
   • Consider bromocriptine (2.5 mg twice daily for 2 weeks, then 2.5 mg daily for 4 weeks) to improve LVEF recovery, though evidence remains limited 1

3. Monitoring:

   • Continuous hemodynamic monitoring during delivery and immediate postpartum period
   • Regular assessment of cardiac function with echocardiography at discharge, 6 weeks, and 6 months 3
   • Monitor for signs of thromboembolism, especially if bromocriptine is used 1

Special Considerations

• Breastfeeding: Generally not advised in PPCM due to potential negative effects of prolactin subfragments on myocardial recovery 1
• Mechanical support: If patient remains hemodynamically unstable despite optimal medical therapy, consider mechanical circulatory support 1
• Long-term follow-up: Essential as these women have increased lifetime cardiovascular risk 3

Pitfalls to Avoid

• Delaying delivery when maternal condition is unstable
• Inadequate blood pressure control (target too low or too high)
• Failure to recognize that HPD-PPCM (hypertensive pregnancy disorder with PPCM) may have different clinical profile than isolated PPCM 4
• Overlooking the need for anticoagulation in patients with severely reduced LVEF
• Assuming all antihypertensive medications are equally effective (nitrates are preferred in PPCM with pulmonary edema) 1