Treatment of Peripartum Cardiomyopathy
Treat peripartum cardiomyopathy aggressively with oxygen, diuretics, and vasodilators in the acute phase, followed by standard heart failure medications postpartum, with special attention to medication safety during pregnancy and the high-risk postpartum period. 1
Acute Management
Immediate stabilization is critical when pulmonary edema or hypoxemia are present 1:
- Oxygen therapy should target arterial oxygen saturation ≥95%, using non-invasive ventilation with PEEP 5-7.5 cmH2O if needed 1
- Intravenous furosemide 20-40 mg IV bolus for congestion and volume overload 1
- Intravenous nitroglycerin 10-20 up to 200 μg/min for patients with systolic blood pressure >110 mmHg (use cautiously if SBP 90-110 mmHg) 1
- Inotropic agents (dobutamine or levosimendan) for signs of hypoperfusion or persistent congestion despite vasodilators and diuretics 1
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 serve as a bridge to recovery or transplantation, particularly 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
Critical medication restrictions apply during pregnancy 1:
- ACE inhibitors and ARBs are absolutely contraindicated due to fetal toxicity 1
- Hydralazine and long-acting nitrates can be used safely as alternatives for afterload reduction 1
- Beta-blockers (preferably β1-selective) can be used safely during pregnancy 1
- Anticoagulation should be strongly considered due to the pro-thrombotic nature of PPCM 1
Postpartum Medication Management
Standard heart failure medications per current guidelines should be initiated postpartum 1:
- ACE inhibitors (captopril, enalapril, and quinapril) have been adequately tested and can be used in breastfeeding women if needed 1
- Bromocriptine may be considered postpartum to enhance cardiac function recovery, but must be accompanied by prophylactic anticoagulation 1
- Continue anticoagulation given the persistent thrombotic risk 1, 2
Labor and Delivery Management
For stable patients with well-controlled cardiac condition, spontaneous vaginal birth is preferable 1. However, 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
Critical Postpartum Period
Close monitoring is essential as most pregnancy-related deaths occur in the first 4 weeks postpartum 1. This high-risk window requires intensive surveillance even in patients who appear stable at delivery.
Long-term Counseling
Careful family planning counseling is critical as the risk of recurrence in subsequent pregnancies is high, especially if LV function has not fully recovered 1, 2. Approximately 30-50% of patients recover without complications, with baseline LV systolic function returning to normal 2. However, mortality rates can reach 5-32%, making this a serious condition requiring long-term cardiac follow-up 3.