Peripartum Cardiomyopathy

Background

• Peripartum cardiomyopathy is idiopathic and presents as heart failure secondary to left ventricular systolic dysfunction during the peripartum period, which encompasses the last month of pregnancy to the first 5 months after delivery.

Evaluation

• Suspect peripartum cardiomyopathy in pregnant women with signs and symptoms of heart failure and in postpartum women with a delayed return to the prepregnancy state with the signs and symptoms of heart failure.
• Use echocardiography to diagnose patients with suspected peripartum cardiomyopathy.
• Consider additional testing, including a chest x-ray or cardiac magnetic resonance imaging, if the results of echocardiography are inconclusive.
• Consider cardiac catheterization and/or myocardial biopsy in selected patients to evaluate for the possibility of ischemia or infection (such as myocarditis) as being causative or contributing factors.

Management

• There is no evidence to support any specific treatment for most patients with peripartum cardiomyopathy.
• The treatment approach remains the same as for other patients with heart failure while taking into account the potential adverse effects of medications during pregnancy or breastfeeding.
• Consider immunosuppressive therapy for myocarditis on endomyocardial biopsy if there is no improvement after 2 weeks of standard heart failure therapy.

During Pregnancy

• Avoid angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and renin inhibitors.
• Consider hydralazine and nitrates to reduce afterload instead of ACE inhibitors and ARBs.
• Consider diuretics only if pulmonary congestion is present.
• Avoid aldosterone antagonists.
• Use beta blockers with caution
  • beta-1 selective drugs (such as metoprolol) preferred
  • avoid atenolol
• Consider the infusion of inotropic agents (such as dobutamine) only if there is severe hypotension and/or signs of cardiogenic shock.

After Delivery

• Provide standard medical therapy for heart failure to patients with peripartum cardiomyopathy, including a combination of the following:
  • beta blockers
  • ACE inhibitors
  • mineralocorticoid receptor antagonists (MRAs)
• Consider the use of bromocriptine which inhibits prolactin release from the pituitary (Weak recommendation).
• Consider an implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) if the symptoms and severe left ventricular dysfunction persist for > 6 months despite optimal medical therapy.
• Consider implantation of a left ventricular assist device in critically ill patients with no signs of recovery over several weeks.
• Consider a heart transplantation in patients who:
  • cannot receive mechanical circulatory support
  • do not improve after 6-12 months with mechanical circulatory support
• See Acute heart failure and Heart Failure With Reduced Ejection Fraction (HFrEF) for additional details on the management of patients with heart failure.