How should peripartum cardiomyopathy be managed in a woman presenting in the last month of pregnancy or within five months postpartum with new left‑ventricular systolic dysfunction (ejection fraction <45%)?

Management of Peripartum Cardiomyopathy

Initiate standard heart failure therapy immediately with diuretics, beta-blockers, and afterload reduction (hydralazine plus nitrates if antepartum, ACE inhibitors or ARBs if postpartum), while adding therapeutic anticoagulation for LVEF <30-35%. 1

Acute Heart Failure Therapy

Diuretics

• Start diuretics immediately for volume overload and symptom relief, as they are safe throughout pregnancy and lactation 1
• Diuretics provide rapid symptomatic improvement in the majority of patients presenting with dyspnea and peripheral edema 1

Beta-Blockers

• Initiate beta-blockers (carvedilol or metoprolol) to reduce myocardial oxygen demand and improve outcomes 1
• Beta-blockers are a cornerstone of therapy and should be started as soon as hemodynamic stability permits 1

Afterload Reduction

• For antepartum patients: use hydralazine plus nitrates because ACE inhibitors are teratogenic 1
• For postpartum patients: start ACE inhibitors or ARBs immediately after delivery to reduce afterload and improve ventricular remodeling 1
• This distinction is critical—ACE inhibitors must be avoided during pregnancy but are preferred postpartum 1

Additional Pharmacotherapy

• Add aldosterone antagonists when symptoms persist despite the above measures 1
• The European Society of Cardiology recommends modifying standard heart failure therapy for breastfeeding safety when applicable 2

Anticoagulation Strategy

Therapeutic anticoagulation is mandatory in specific high-risk scenarios:

• Initiate anticoagulation when LVEF <30-35% and continue for 6-8 weeks postpartum, as intracardiac thrombi occur in 16-17% of this subgroup 1
• Documented left ventricular thrombus on echocardiography or cardiac MRI mandates anticoagulation 1
• Presence of atrial fibrillation or other clinically significant arrhythmias requires anticoagulation 1
• The European Society of Cardiology recommends anticoagulation if LVEF <35% due to high thromboembolic risk 2

Risk Stratification and Monitoring

Severe Disease (LVEF <30%)

• Patients with LVEF <30% have the highest mortality risk and require mandatory anticoagulation plus early referral for advanced heart failure therapies such as LVAD or transplant evaluation 1
• The European Journal of Heart Failure identifies LVEF <30% and LV end-diastolic diameter >60 mm as predictors of poor recovery 2

Moderate Disease (LVEF 30-45%)

• Manage with standard heart failure therapy and close follow-up 1
• These patients still require intensive monitoring but have better recovery potential 1

Recovery Timeline

• Approximately 78% of left ventricular functional recovery occurs within the first four months after delivery 1
• About 30-50% of patients recover completely with baseline LV systolic function returning to normal 3
• Persistence of disease after 6 months indicates irreversible cardiomyopathy and portends worse survival 4

Serial Echocardiographic Assessment

Schedule repeat echocardiography at specific intervals:

• Before hospital discharge 2
• At 6-8 weeks postpartum 2, 1
• At 3 months 1
• At 6 months 2, 1
• Annually thereafter 2

These assessments track recovery trajectory and guide decisions about device therapy and future pregnancy 1

Race-Specific Considerations

• Incidence is markedly higher in individuals of African ancestry (≈1:1,421) compared with White individuals (≈1:4,075) 1
• African-ancestry patients exhibit higher rates of persistent LV dysfunction and more severe initial presentations 1
• Some geographic regions report increased mortality among African-ancestry patients, supporting a lower threshold for aggressive intervention and intensified follow-up 1

Device Therapy Considerations

Thresholds for devices (implantable cardioverter-defibrillators, cardiac resynchronization therapy, and implanted long-term ventricular assist devices) are higher in PPCM than in other conditions because of the high rate of recovery 5

This means you should delay permanent device implantation decisions until adequate time has passed to assess recovery potential, typically 6 months 5

Emerging Disease-Specific Therapy

• Bromocriptine (dopamine D2 receptor agonist) blocks prolactin release and has shown promising results in two clinical trials as disease-specific therapy 5
• The pathophysiology involves oxidative stress-mediated cleavage of prolactin into a cardiotoxic 16 kDa fragment that inhibits endothelial cell proliferation and induces apoptosis 6, 5
• Bromocriptine is used in addition to standard heart failure therapy, not as a replacement 5

Future Pregnancy Counseling

Absolute Contraindications

• Persistent LV dysfunction (LVEF <50%) constitutes an absolute contraindication to subsequent pregnancy 1
• The American College of Cardiology strongly advises against subsequent pregnancy if LVEF <25% at diagnosis or if LVEF has not normalized 2

Risk in Recovered Patients

• Even after complete recovery (LVEF ≥50%), subsequent pregnancy carries a 27% risk of LVEF deterioration and a 32% risk of recurrent heart failure, although mortality in this group is 0% 1
• In women with ongoing dysfunction, 48% experience further LVEF decline, 49% develop recurrent heart failure symptoms, and 16% succumb to mortality 1

Contraception Recommendations

• Intrauterine devices and progesterone-only contraception are recommended 2
• Combined hormonal contraceptives should be avoided due to increased thromboembolism risk 2
• Permanent contraception or high-risk pregnancy counseling with pre-conception cardiology evaluation is recommended for all women with a history of PPCM, regardless of current LV function 1

Multidisciplinary Care

Management requires mandatory cardiology consultation and access to intensive-care resources for patients presenting with NYHA class III-IV symptoms, which represent the majority of cases 1

Common Pitfalls to Avoid

• Do not delay diagnosis by attributing dyspnea, fatigue, and leg edema to normal pregnancy—maintain a high index of suspicion 5
• Do not use ACE inhibitors during pregnancy—switch to hydralazine plus nitrates 1
• Do not withhold anticoagulation in patients with LVEF <30-35%—the thromboembolic risk is substantial 1
• Do not rush to permanent device implantation—allow time for recovery assessment given the high recovery rate 5
• Do not approve subsequent pregnancy without documented full recovery (LVEF ≥50%) and comprehensive counseling about residual risks 1