Can a woman with a history of peripartum cardiomyopathy and LVEF of 28% safely become pregnant again?

From the Guidelines

The patient should be strongly advised against another pregnancy due to her persistent reduced left ventricular ejection fraction (LVEF) of 28%, as this significantly increases her risk for serious cardiac complications, including heart failure exacerbation, arrhythmias, and even death during a subsequent pregnancy. Despite her subjective improvement in symptoms and exercise tolerance over the past two years, her cardiac function remains significantly impaired. According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, patients with peripartum cardiomyopathy who have persistent LVEF below 50% are at high risk for serious cardiac complications during a subsequent pregnancy. The hemodynamic changes of pregnancy, including increased blood volume and cardiac output, place substantial additional strain on an already compromised heart.

Some key points to consider in this patient's care include:

• The risk of intracardiac thrombus formation is significant in patients with severely reduced systolic function, and anticoagulation may be considered in certain cases 1.
• The use of bromocriptine for postpartum women with severe acute heart failure caused by peripartum cardiomyopathy and LVEF <35% should be accompanied by at least prophylactic-dosed anticoagulation due to the potential association with thromboembolic events 1.
• Effective contraception should be emphasized until a definitive family planning decision is made, and options such as intrauterine devices, progesterone-only contraception, and sterilization can be considered 1.
• If the patient is determined to have another child, alternative options such as adoption or surrogacy should be discussed.

The patient should continue to be followed by a cardiologist, and if she wishes to pursue pregnancy despite the risks, a multidisciplinary approach involving maternal-fetal medicine specialists and cardiologists would be essential to manage her care, though the recommendation would still be against pregnancy given her current cardiac status.

From the Research

Patient's Condition and Medical History

• The patient is a 29-year-old woman with a history of peripartum cardiomyopathy, diagnosed after her first pregnancy.
• She had a left ventricular ejection fraction of 21% at the time of diagnosis, which has improved to 28% in recent echocardiograms.
• The patient's symptoms have also improved, with increased walking and exercise tolerance.

Risks Associated with Another Pregnancy

• Peripartum cardiomyopathy confers a substantial risk of relapse and even death if there is incomplete myocardial recovery 2, 3.
• The patient's left ventricular ejection fraction, although improved, is still below the normal range, indicating ongoing cardiac dysfunction.
• The risk of acute clinical decompensation, cardiac arrhythmias, thromboembolic complications, and death is increased in patients with peripartum cardiomyopathy 3, 4.

Considerations for Another Pregnancy

• The patient's desire to attempt another pregnancy must be weighed against the potential risks to her health.
• The medical management of peripartum cardiomyopathy is similar to heart failure with reduced ejection fraction of other etiologies, but adjustments during pregnancy are necessary to ensure fetal safety 2.
• The use of bromocriptine, a dopamine agonist, has been shown to improve outcomes in patients with peripartum cardiomyopathy by suppressing prolactin release and preventing myocardial dysfunction 4, 5.

Most Appropriate Response

• The most appropriate response to the patient would be to discuss the potential risks and benefits of another pregnancy, taking into account her improved symptoms and left ventricular ejection fraction.
• A multidisciplinary approach, involving cardiologists, obstetricians, and other healthcare professionals, would be necessary to manage the patient's care and minimize the risks associated with another pregnancy 2, 3.