Treatment for Peripartum Cardiomyopathy
The treatment for peripartum cardiomyopathy follows standard heart failure management protocols with specific considerations for pregnancy status, including oxygen therapy, diuretics, vasodilators, and inotropic support for acute cases, followed by standard heart failure medications postpartum. 1
Acute Management
Initial Treatment
- Rapid treatment is essential, especially when pulmonary edema and/or hypoxemia are present 1
- Oxygen should be administered to achieve arterial oxygen saturation ≥95%, using non-invasive ventilation with PEEP 5-7.5 cmH2O if necessary 1
- Intravenous diuretics (furosemide 20-40 mg IV bolus) for congestion and volume overload 1
- Intravenous nitrates (nitroglycerin 10-20 up to 200 μg/min) for patients with systolic blood pressure >110 mmHg; use with caution if SBP between 90-110 mmHg 1
Advanced Support
- Inotropic agents (dobutamine, levosimendan) should be considered in patients with:
- Mechanical circulatory support should be considered if the patient remains dependent on inotropes or intra-aortic balloon pump despite optimal medical therapy 1
- LVAD may be considered as a bridge to recovery or transplantation, especially since PPCM has a higher recovery rate than other forms of dilated cardiomyopathy 1
- Cardiac transplantation should be considered if weaning from mechanical support is unsuccessful 1
Medication Management
During Pregnancy
- ACE inhibitors and ARBs are contraindicated due to fetal toxicity 1
- Hydralazine and long-acting nitrates can be used safely instead of ACE inhibitors/ARBs 1
- Beta-blockers (preferably β1-selective) can be used safely 1
- Anticoagulation should be considered due to the pro-thrombotic nature of PPCM 1, 2
Postpartum
- Standard heart failure medications per current guidelines 1
- Bromocriptine may be considered postpartum to enhance cardiac function recovery, but must be accompanied by prophylactic anticoagulation 1
- Several ACE inhibitors (captopril, enalapril, and quinapril) have been adequately tested and can be used in breastfeeding women if needed 1
Labor and Delivery Management
- For stable patients with well-controlled cardiac condition, spontaneous vaginal birth is preferable 1
- Planned cesarean section is preferred for critically ill women requiring inotropic therapy or mechanical support 1
- Labor should be conducted in a high-care area with experience managing cardiac disease in pregnancy 1
- Continuous invasive hemodynamic monitoring and urinary catheter drainage are recommended 1
- Epidural analgesia is preferred during labor as it stabilizes cardiac output 1
- Avoid prolonged bearing down efforts; consider low forceps or vacuum-assisted delivery to shorten the second stage 1
- Ergometrine is contraindicated; use single dose of intramuscular oxytocin for third stage management 1
- Consider a single IV dose of furosemide after delivery to manage auto-transfusion of blood 1
Special Considerations
- Breastfeeding is generally not advised in PPCM patients due to potential negative effects of prolactin subfragments, although this recommendation is not fully evidence-based 1
- Anticoagulation is recommended due to increased risk of venous thromboembolism 2
- Close monitoring is essential as most pregnancy-related deaths occur in the first 4 weeks postpartum 1
- About 30-50% of patients recover without complications, with baseline LV systolic function returning to normal 2
Long-term Follow-up
- Careful family planning counseling is important as the risk of recurrence in subsequent pregnancies is high, especially if LV function has not fully recovered 1, 3
- All women with PPCM should have close follow-up with a cardiologist 3
- Women considering subsequent pregnancy require preconception counseling and collaborative care between cardiology and obstetrics 3