How should a woman who develops new‑onset systolic heart failure in the last month of pregnancy or within five months postpartum be evaluated and managed for suspected peripartum cardiomyopathy?

Peripartum Cardiomyopathy: Evaluation and Management

A woman presenting with new-onset systolic heart failure in the last month of pregnancy or within five months postpartum should undergo immediate transthoracic echocardiography to confirm LVEF < 45%, followed by prompt initiation of heart failure therapy including diuretics, beta-blockers, and vasodilators (hydralazine plus nitrates if antepartum, ACE inhibitors if postpartum), with therapeutic anticoagulation mandatory when LVEF < 30-35%. 1, 2

Diagnostic Confirmation

Echocardiography is the cornerstone of diagnosis and must be performed immediately when peripartum cardiomyopathy (PPCM) is suspected. 1, 2

• LVEF < 45% is present in virtually all cases and is required for diagnosis 1, 2
• Left ventricular thrombus screening is critical, as thrombi occur in 16-17% of patients with LVEF < 35% 1, 2
• Right ventricular involvement should be actively assessed, as it predicts worse prognosis 2
• Left ventricular end-diastolic dimension > 2.7 cm/m² body surface area may be present but is not required 3

Additional diagnostic tests include:

• 12-lead ECG, which is abnormal in 96% of patients, most commonly showing ST-T wave changes (96%) and left ventricular hypertrophy voltage criteria (66%) 1, 2
• BNP or NT-proBNP levels, which are elevated in every patient with PPCM 1, 2
• Comprehensive work-up to exclude coronary artery disease, significant valvular disease, congenital heart disease, hypertensive heart disease, and pulmonary embolism 2

Physical examination findings include displaced apical impulse (72% of patients), third heart sound S3 (92%), and functional mitral regurgitation (43%). 2

Acute Heart Failure Management

Antepartum Treatment (Before Delivery)

Diuretics should be initiated immediately for volume overload and symptom relief; they are safe throughout pregnancy and lactation. 1

Beta-blockers (carvedilol or metoprolol) must be started to lower myocardial oxygen demand and improve outcomes. 1

Vasodilator therapy with hydralazine plus nitrates is the recommended afterload reduction strategy during pregnancy because ACE inhibitors are teratogenic. 1

Postpartum Treatment (After Delivery)

ACE inhibitors or ARBs should be initiated immediately after delivery to reduce afterload. 1

Aldosterone antagonists can be added when symptoms persist despite the above measures. 1

Beta-blockers and diuretics continue as in antepartum management. 1

Anticoagulation Strategy

Therapeutic anticoagulation is mandatory in specific high-risk scenarios:

• LVEF < 30-35% requires anticoagulation for 6-8 weeks postpartum due to 16-17% incidence of intracardiac thrombi 1, 2
• Documented left ventricular thrombus on echocardiography or cardiac MRI mandates anticoagulation 1, 2
• Atrial fibrillation or other clinically significant arrhythmias require anticoagulation 1

The high thromboembolic risk in severe PPCM includes cerebral, coronary, and mesenteric emboli. 2

Risk Stratification and Monitoring

Patients with LVEF < 30% have the highest mortality risk and require:

• Mandatory anticoagulation 1
• Early referral for advanced heart failure therapies including LVAD or transplant evaluation 1
• Intensive care unit admission for NYHA class III-IV symptoms 1

Patients with LVEF 30-45% are managed with standard heart failure therapy and close follow-up. 1

Serial echocardiographic assessments should be performed at 6-8 weeks, 3 months, and 6 months to track recovery trajectory, as approximately 78% of left ventricular functional recovery occurs within the first four months after delivery. 1

Race-Specific Considerations

African ancestry patients require heightened vigilance:

• Incidence is markedly higher (≈1:1,421) compared with White individuals (≈1:4,075) 1
• Higher rates of persistent LV dysfunction and more severe initial presentations 1
• Increased mortality in some geographic regions, supporting a lower threshold for aggressive intervention and intensified follow-up 1

Future Pregnancy Counseling

Persistent LV dysfunction (LVEF < 50%) is an absolute contraindication to subsequent pregnancy. 1

In women with ongoing dysfunction:

• 48% experience further LVEF decline 1
• 49% develop recurrent heart failure symptoms 1
• 16% mortality rate 1

Even after complete recovery (LVEF ≥ 50%), subsequent pregnancy carries:

• 27% risk of LVEF deterioration 1
• 32% risk of recurrent heart failure 1
• 0% mortality (though still significant morbidity) 1

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

Critical Clinical Pitfalls to Avoid

Delayed diagnosis is the most common error. Clinicians must maintain high suspicion during the first 2-3 months postpartum and avoid attributing dyspnea, peripheral edema, or fatigue to normal pregnancy-related changes. 2

Failure to perform prompt echocardiography can allow rapid progression to end-stage heart failure within days. 2

Omitting anticoagulation in patients with LVEF < 35% leads to preventable thromboembolic complications and must be avoided. 2

Misattributing symptoms to normal postpartum changes delays diagnosis, as typical presenting symptoms (exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, marked peripheral edema beyond normal pregnancy edema, persistent cough, and abdominal discomfort from hepatic congestion) overlap with physiological pregnancy discomforts. 4, 2

Multidisciplinary Care Requirements

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