From the Guidelines
Postpartum cardiomyopathy (PPCM) is a rare but serious form of heart failure that occurs in previously healthy women during the last month of pregnancy or within five months after delivery, and its management should prioritize guideline-directed medical therapy (GDMT) and prophylactic anticoagulation for severe cases, as recommended by the 2022 AHA/ACC/HFSA guideline 1.
Definition and Pathophysiology
PPCM is characterized by left ventricular ejection fraction (LVEF) <45% and no other identifiable cause of cardiomyopathy. The pathophysiology of PPCM involves complex interactions between hormonal, immune, and genetic factors, with prolactin playing a potential role.
Management Plan
The management of PPCM requires a multidisciplinary approach, including cardiology, obstetrics, and maternal-fetal medicine teams. For postpartum women with severe acute HF caused by PPCM and LVEF <35%, GDMT pharmacotherapy and prophylactic anticoagulation are recommended to improve LVEF recovery 1.
- Nonpharmacological strategies include close maternal monitoring, echocardiographic screening, and consideration of routine echocardiographic screening in the third trimester.
- Pharmacological strategies include the use of beta blockers, hydralazine, and nitrates during pregnancy, and the consideration of anticoagulation until 6-8 weeks postpartum for women with acute HF caused by PPCM and LVEF <30%.
- Bromocriptine may be considered for women with LVEF <25% or cardiogenic shock, but its use should be accompanied by at least prophylactic-dosed anticoagulation due to potential hypercoagulability.
Key Considerations
- Breastfeeding should be approached with caution, and medications should be reviewed with neonatology and pediatrics teams for neonatal safety during lactation.
- Multidisciplinary management with obstetrics, maternal-fetal medicine, neonatology, and pediatrics teams is essential, especially for multidisciplinary recommendations regarding lactation.
- Consultation with gynecology team for ongoing contraceptive planning is recommended.
- Close monitoring with regular echocardiograms is essential, and patients with persistent severe dysfunction may require advanced therapies like implantable cardioverter-defibrillators or heart transplantation.
From the Research
Definition of Postpartum Cardiomyopathy
- Postpartum cardiomyopathy (PPCM) is a rare, life-threatening heart disease of unclear origin, characterized by heart failure of sudden onset between the final weeks of pregnancy and 6 months after delivery 2.
- It is a serious pregnancy-associated disorder of unknown etiology, with the precise cellular and molecular mechanisms underlying PPCM being unclear 3.
- PPCM typically presents in the third trimester or in the first few months postpartum, with clinical progression varying considerably 4, 5.
Management Plan
- Treatment with ACE inhibitors, diuretics, aldosterone antagonists, and beta-blockers is required, although ACE inhibitors and ARBs should be avoided during pregnancy or lactation 3, 2.
- Beta-blockers, preferably metoprolol, should be started if no contraindications exist 6, 3.
- Experimental therapies like bromocriptine, pentoxifylline, and immunoglobulins have shown promising results, but large double-blind randomized trials are essential to confirm the results of smaller studies 3, 4.
- In patients with persistent severe left ventricular dysfunction, advanced therapies like mechanical circulatory support and heart transplantation should be considered 3, 4.
- Women with PPCM should be managed by a multidisciplinary team with experience in high-risk pregnancy and the treatment of heart failure 4.
Breastfeeding Considerations
- Breastfeeding should not routinely be ruled out if the mother is taking heart failure medication, but the consequences for the infant need to be considered 5.
- An informed risk assessment to minimize potential harm to the infant can be carried out using the evidence that is available, along with a consideration of drug properties, adverse effects, pediatric use, and pharmacokinetics 5.
- In most cases, risks can be managed, and infants can be monitored for potential problems, allowing breastfeeding to be encouraged in women with cardiac dysfunction with PPCM 5.