Cardiac disease in pregnancy and peripartum cardiomyopathy: Difference between revisions

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__NOTOC__
{{Cardiac disease in pregnancy}}
{{Cardiac disease in pregnancy}}
{{CMG}}; {{AOEIC}} {{CZ}}; {{AC}}
{{CMG}}; {{AOEIC}} {{AC}}


'''''Synonyms and Keywords:''''' PPCM;  
'''''Synonyms and Keywords:''''' PPCM; PPCMP


==Overview==
==Overview==
Peripartum cardiomyopathy ''([[PPCM]])'' is a form of [[dilated cardiomyopathy]] that is defined as a deterioration in cardiac function presenting between the last month of gestation and up to five months post-partum.  
Peripartum cardiomyopathy ''([[PPCM]])'' is a form of [[dilated cardiomyopathy]] that is defined as a deterioration in cardiac function presenting between the last month of gestation and up to six months post-partum. The etiology of postpartum cardiomyopathy is unknown. Reported prevalence of postpartum cardiomyopathy in United States is estimated to be 1 case per 1300-15,000 live births. Treatment for the disease is similar to treatment for [[congestive heart failure]]. [[Delivery]] is the recommeded overall treatment to decrease the volume load, improve ventricular function and simplify the medical management of these patients.
 
The etiology of postpartum cardiomyopathy is unknown. As with other forms of [[dilated cardiomyopathy]], [[PPCM]] involves decrease of the [[left ventricle|left ventricular]] [[ejection fraction]] with associated [[congestive heart failure]] and increased risk of atrial and ventricular [[arrhythmia]]s and even [[sudden cardiac death]].
 
In the US the prevalence is estimated to be 1 case per 1300-15,000 live births. The incidence of peripartum cardiomyopathy is increased in women over the age of 30, in twin pregnancies, in multiparous women, in women with gestational hypertension, those who have received tocolytic therapy, and in african americans.
 
Treatment for the disease is similar to treatment for [[congestive heart failure]]. [[Delivery]] is the recommeded overall treatment to decrease the volume load, improve ventricular function and simplify the medical management of these patients.


==Definition==
==Definition==
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:*End-diastolic dimension >2.7 cm/m2 BSA (body surface area)
:*End-diastolic dimension >2.7 cm/m2 BSA (body surface area)


==Common Mimickers==
==Pathophysiology==
The etiology of postpartum cardiomyopathy is largely unknown. It has been postulated that a defective antioxidant mechanism may contribute.  There are elevated levels of [[cathepsin D]] and an increase in total prolactin and angiostatic 16kDa [[prolactin]].  These molecules promote:
*[[Apoptosis]]
*Inhibit endothelial cell proliferation
*Increase [[vasoconstriction]]
*Impair [[myocyte]] function
 
The potential role of [[prolactin]] forms the molecular basis of treatment with [[bromocriptine]].
 
As with other forms of [[dilated cardiomyopathy]], [[PPCM]] involves decrease of the [[left ventricle|left ventricular]] [[ejection fraction]] with associated [[congestive heart failure]] and increased risk of atrial and ventricular [[arrhythmia]]s and even [[sudden cardiac death]].
 
==Differentiating Peripartum Cardiomyopathy from Other Diseases==


* Accelerated [[HTN]]
* Accelerated [[HTN]]
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* High output state of pregnancy
* High output state of pregnancy


==Demographics==
==Epidemiology and Demographics==
 
*Estimates of incidence 1/1300-15000. Previous studies likely overestimated
*More common in women with:
:*Multiple pregnancies
:*African decent
:*h/o toxemia
:*Long-term tocolytic use
:*Age>30
:*Twin Pregnancy


==Hemodynamic Findings==
*Estimates of incidence 1/1,300-15,000.


{| border="1" cellpadding="2"
==Risk Factors==
!width="100"|Chamber
PPCM is more common among women with:
!width="225"|Normal Pregnancy
*Prior PPCM
!width="225"|Peripartum cardiomyopathy
*Multiple pregnancies
|-
*African decent, Haitian descent
|align="center"|RA ||align="center"|2 || align="center"|11 (2-34)
*History of [[toxemia]]
|-
*Long-term [[tocolytic]] use
|align="center"|PA ||align="center"|11 || align="center"|39 (18-62)
*Age >30
|-
*Twin Pregnancy
|align="center"| PCW ||align="center"| 6 || align="center"|18 (5-32)
|-
|align="center"|CO (L/min) ||align="center"| 7 ||align="center"|6  (5-9)
|-
|align="center"|HR  ||align="center"|83 ||align="center"|104  (76-142)
|}


==Treatment of Peripartum Cardiomyopathy==
==Natural History, Complications and Prognosis==
*Some patients will have a relapse of PPCM after a partial or full recovery.
*The course of peripartum CMP is variable.
*PPCM is a leading cause of pregnancy related death in the United States.
* Mortality 25-50% (half deaths in first 3 months).
* 50% improve within 6 months.
*20% to 40% of patients normalize their [[LVEF]].
*If the [[LVEF]] remains poor at 6 months, then mortality is increased.
* PPCM is a risk factor for recurrence with subsequent pregnancies.
* Favorable outcomes with [[cardiac transplantation]].


* [[Digoxin]] and diuretics are Class C
==Diagnosis==
* [[ACE inhibitors]] absolutely contraindicated prepartum ([[hydralazine]] drug of choice)
===History and Symptoms===
* Anticoagulation recommended ([[Heparin]] prepartum and [[coumadin]] postpartum)
Signs and symptoms are similar to those of normal pregnancy


==Outcome of Peripartum Cardiomyopathy==
==Treatment==
===Medical Therapy===


* Mortality 25-50% (half deaths in first 3 months)
* [[Delivery]] is the recommeded overall treatment to decrease the volume load, improve ventricular function and simplify the medical management of these patients.
* Remainder stable/recover within 6 months
====Pharmacotherapy====
* Can recur with subsequent pregnancies
Pharmacotherapy should be discontinued or tapered gradually based upon repeated echocardiographic analyses.  Some patients will have a relapse of PPCM after a partial or full recovery.
* Favorable outcomes with cardiac transplantation
*[[Bromocriptine]] blocks release of [[prolactin]] (see pathophysiology regarding role of [[prolactin]]). This therapy has been shown to increase the [[left ventricular ejection fraction]] ([[LVEF]]) versus standard treatment.  As a side effect, this drug will inhibit [[lactation]].
* [[Digoxin]] and [[diuretics]] are [[pregnancy category]] Class C agents and can be used if the benefits outweigh the risks.
* [[ACE inhibitors]] absolutely contraindicated prepartum ([[hydralazine]] drug of choice).
* [[Anticoagulation]] recommended ([[heparin]] prepartum and [[coumadin]] postpartum) if the [[left ventricular ejection fraction]] ([[LVEF]]) is <35%.
===Surgery===
*[[Ventricular assist device]] or [[cardiac transplantation]] can be performed in patients with severe refractory [[congestive heart failure]].


==References==
==References==
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Latest revision as of 20:48, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Anjan K. Chakrabarti, M.D. [2]

Synonyms and Keywords: PPCM; PPCMP

Overview

Peripartum cardiomyopathy (PPCM) is a form of dilated cardiomyopathy that is defined as a deterioration in cardiac function presenting between the last month of gestation and up to six months post-partum. The etiology of postpartum cardiomyopathy is unknown. Reported prevalence of postpartum cardiomyopathy in United States is estimated to be 1 case per 1300-15,000 live births. Treatment for the disease is similar to treatment for congestive heart failure. Delivery is the recommeded overall treatment to decrease the volume load, improve ventricular function and simplify the medical management of these patients.

Definition

Peripartum cardiomyopathy is defined as:

  • Ejection fraction <45% and/or
  • Fractional shortening <30%
  • End-diastolic dimension >2.7 cm/m2 BSA (body surface area)

Pathophysiology

The etiology of postpartum cardiomyopathy is largely unknown. It has been postulated that a defective antioxidant mechanism may contribute. There are elevated levels of cathepsin D and an increase in total prolactin and angiostatic 16kDa prolactin. These molecules promote:

The potential role of prolactin forms the molecular basis of treatment with bromocriptine.

As with other forms of dilated cardiomyopathy, PPCM involves decrease of the left ventricular ejection fraction with associated congestive heart failure and increased risk of atrial and ventricular arrhythmias and even sudden cardiac death.

Differentiating Peripartum Cardiomyopathy from Other Diseases

Epidemiology and Demographics

  • Estimates of incidence 1/1,300-15,000.

Risk Factors

PPCM is more common among women with:

  • Prior PPCM
  • Multiple pregnancies
  • African decent, Haitian descent
  • History of toxemia
  • Long-term tocolytic use
  • Age >30
  • Twin Pregnancy

Natural History, Complications and Prognosis

  • Some patients will have a relapse of PPCM after a partial or full recovery.
  • The course of peripartum CMP is variable.
  • PPCM is a leading cause of pregnancy related death in the United States.
  • Mortality 25-50% (half deaths in first 3 months).
  • 50% improve within 6 months.
  • 20% to 40% of patients normalize their LVEF.
  • If the LVEF remains poor at 6 months, then mortality is increased.
  • PPCM is a risk factor for recurrence with subsequent pregnancies.
  • Favorable outcomes with cardiac transplantation.

Diagnosis

History and Symptoms

Signs and symptoms are similar to those of normal pregnancy

Treatment

Medical Therapy

  • Delivery is the recommeded overall treatment to decrease the volume load, improve ventricular function and simplify the medical management of these patients.

Pharmacotherapy

Pharmacotherapy should be discontinued or tapered gradually based upon repeated echocardiographic analyses. Some patients will have a relapse of PPCM after a partial or full recovery.

Surgery

References


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