What is the treatment for peripartum cardiomyopathy?

Treatment for Peripartum Cardiomyopathy

The treatment for peripartum cardiomyopathy requires rapid intervention with standard heart failure medications, tailored to pregnancy status, including oxygen therapy, diuretics, vasodilators, and inotropic support for acute cases, with mechanical circulatory support considered for refractory cases. 1

Acute Management

• Administer oxygen therapy to achieve arterial oxygen saturation ≥95%, using non-invasive ventilation with PEEP 5-7.5 cmH2O if necessary 1
• Provide intravenous diuretics (furosemide 20-40 mg IV bolus) for congestion and volume overload 1
• Use intravenous nitrates (nitroglycerin 10-20 up to 200 μg/min) for patients with systolic blood pressure >110 mmHg, with caution if SBP between 90-110 mmHg 1
• Consider inotropic agents (dobutamine, levosimendan) for patients with signs of hypoperfusion or persistent congestion despite vasodilators and diuretics 1
• Implement mechanical circulatory support if the patient remains dependent on inotropes despite optimal medical therapy 1
• Consider LVAD as a bridge to recovery or transplantation, especially since PPCM has a higher recovery rate than other forms of dilated cardiomyopathy 1
• Evaluate for cardiac transplantation if weaning from mechanical support is unsuccessful 1

Medication Management During Pregnancy

• Avoid ACE inhibitors and ARBs during pregnancy due to fetal toxicity 1
• Use hydralazine and long-acting nitrates as safe alternatives during pregnancy 1
• Administer beta-blockers (preferably β1-selective) which can be used safely during pregnancy 1
• Initiate anticoagulation due to the pro-thrombotic nature of PPCM 1

Postpartum Medication Management

• Transition to standard heart failure medications per current guidelines 1
• Consider bromocriptine to enhance cardiac function recovery, but always with prophylactic anticoagulation 1
• Select ACE inhibitors that have been adequately tested for breastfeeding women (captopril, enalapril, and quinapril) 1

Labor and Delivery Management

• For stable patients with well-controlled cardiac condition, favor spontaneous vaginal birth 1
• Recommend planned cesarean section for critically ill women requiring inotropic therapy or mechanical support 1
• Conduct labor in a high-care area with experience managing cardiac disease in pregnancy 1
• Implement continuous invasive hemodynamic monitoring and urinary catheter drainage 1
• Use epidural analgesia during labor to stabilize cardiac output 1
• Avoid prolonged bearing down efforts; consider low forceps or vacuum-assisted delivery to shorten the second stage 1
• Avoid ergometrine; use single dose of intramuscular oxytocin for third stage management 1
• Administer a single IV dose of furosemide after delivery to manage auto-transfusion of blood 1

Long-term Follow-up and Prognosis

• Approximately 30-50% of patients recover without complications, with baseline LV systolic function returning to normal 2
• Provide careful family planning counseling as the risk of recurrence in subsequent pregnancies is high, especially if LV function has not fully recovered 1, 2
• Continue close monitoring as most pregnancy-related deaths occur in the first 4 weeks postpartum 1
• For women with normalized LV function (confirmed by echocardiography and dobutamine stress testing), the risk of severe cardiomyopathy including death is relatively lower in subsequent pregnancies 2

Special Considerations

• Early diagnosis and prompt initiation of treatment are essential to optimize outcomes 3
• Ensure multidisciplinary care involving cardiology, obstetrics, maternal-fetal medicine, anesthesiology, and nursing 3
• Persistent disease after 6 months indicates irreversible cardiomyopathy and portends worse survival 4
• All women with PPCM should have close follow-up with a cardiologist, even after recovery 3