What is Postpartum Cardiomyopathy (Peripartum Cardiomyopathy?)
According to the American Heart Association, postpartum Cardiomyopathy (PPCM) is a rare form of heart failure where the heart muscle weakens during the last month of pregnancy and continues for approximately five months postpartum. It is a form of dilated cardiomyopathy in which the muscles in the heart ventricles are weaker because it gets thinner and stretches as they grow larger.
Because it can start during pregnancy (peripartum period), the condition is also referred to as Peripartum Cardiomyopathy. Typically, PPCM begins shortly after giving birth. PPCM is defined as idiopathic cardiomyopathy as the cause is not always known.
With diminished heart function and blood flow, the heart is unable to deliver sufficient oxygen to the body’s organs and adversely affects the pulmonary and cardiovascular systems, liver and other systems.
The incidence of PPCM is rare in the United States; PPCM is diagnosed between 1 in 1141 to 1 in 4350 live births each year.
What Are the Symptoms of Postpartum Cardiomyopathy?
The symptoms of postpartum cardiomyopathy depend on the severity of the case. Some symptoms of PPCM include:
- Fatigue
- Shortness of breath during activity and when lying flat
- Swollen ankles, feet and legs
- Heart palpitations, or tachycardia (faster than normal heart rate)
- Swollen neck veins
- Low blood pressure
- Increased urination in the evening
The clinical characteristics of a mild case of PPCM may go undiagnosed as these symptoms of heart failure are similar to those of the third trimester of a normal pregnancy. In these cases, the patient’s symptoms may go away on their own without additional medical treatment.
In severe cases, symptoms include swollen ankles and feet, and severe shortness of breath well after giving birth.
How is it Diagnosed?
When the heart function has decreased, it can’t effectively pump and fluid can build up in the lungs. A medical professional will use a stethoscope to look for signs of fluid in the lungs such as abnormal heart sounds, tachycardia or crackling lung sounds during breathing.
An echocardiogram is a noninvasive procedure that uses sound waves to assess the heart’s function and structure and detect heart failure. Echocardiography can detect cardiomyopathy as it can show whether a heart has reduced functioning and can measure its ejection fraction.
The ejection fraction is the percentage of blood the left ventricle pumps out with each contraction. In a healthy heart, the ejection fraction is between 55% and 70%.
A diagnosis of PPCM occurs when a patient meets the following three criteria:
- Heart failure develops sometime between the last month of pregnancy and during the 5 months postpartum period
- An ejection fraction less than 45%
- The cause of heart failure cannot be determined
In addition, blood tests would be administered to determine the level of risk. Some tests include a complete blood count, tests to assess electrolyte levels and tests to assess liver, kidney and thyroid function.
What Are the Risk Factors?
The etiology of PPCM is not defined; however, medical experts believe the cause is due to two factors. During pregnancy, in order to transport essential nutrients and oxygen to a growing fetus, the heart has to pump up to 50 percent more blood. The combination of the additional work the heart does during pregnancy and other high risk factors increases the chance of PPCM.
Some predictors that can increase the risk of developing PPCM are:
- Obesity
- Smoking
- Coronary artery disease
- Hypertension (high blood pressure)
- Preeclampsia
- Excessive alcohol use
- History of cardiac diseases such as myocarditis (inflammation of the heart muscle), heart disease, and heart valve dysfunction
- Inherited diseases
- Diabetes
- Malnutrition
- Multiple pregnancies
- Older maternal age
- African-American descent
What Are the Treatment Options for Postpartum Cardiomyopathy?
PPCM patients stay in the hospital until their symptoms are under control. Treatment for PPCM focuses on preventing extra fluid from building up in the lungs and ensuring the heart recovers fully. A doctor determines the type of treatment depending on the severity of a patient’s condition.
The rate of recovery is not affected by how severe the condition is. For instance, a patient who has a very low ejection fraction can completely recover. Generally, most patients with PPCM get better with time.
Some patients take as little as two weeks for their hearts to return back to their normal strength. Other patients may take over six months and only recover part of their heart function.
In extremely severe cases, a cardiologist may recommend a heart transplant. This is very unlikely; heart transplantation as a treatment option occurs in only 4% of all PPCM cases. Of those who receive transplants, 9% die from the procedure. Some complications associated with PPCM include congestive heart failure, arrhythmia, blood clots in the lungs, and death. The estimated death rate associated with peripartum cardiomyopathy in the United States is between 6% to 10%.
However, for most patients, treatment involves decreasing and managing symptoms.
A cardiologist may prescribe certain medications to help stabilize the condition and treat the symptoms. Safer variations that are equally effective are available for breastfeeding patients.
- Angiotensin-converting enzyme (ACE) inhibitors: ACE inhibitors help the heart pump more efficiently.
- Beta-blockers: This medication gives the heart more time to recover by slowing the heart rate.
- Diuretics: These medications help decrease fluid retention.
- Digitalis: This medication helps increase the heart’s pumping ability.
- Anticoagulants: A low ejection fraction can cause PPCM patients to have a high risk of developing blood clots. These medications help thin the blood.
Healthcare professionals may recommend lifestyle changes to manage PPCM symptoms. Patients are advised to avoid smoking and drinking as this can exacerbate symptoms. A low-sodium diet is recommended to manage hypertension and eclampsia symptoms.
The latest treatment research focuses on the effects of the hormone prolactin on the heart. Prolactin is released during the last trimester of pregnancy to stimulate the production of breast milk. However, prolactin may also limit blood supply to the heart muscle which can cause cell death. Bromocriptine is a medication that prevents the release of prolactin.
A systematic review showed that the combination of bromocriptine and traditional heart failure treatment improved the left ventricular function among females with acute PPCM and their clinical outcomes. However, further clinical trials are required.
Is it Safe to Have a Subsequent Pregnancy?
It is important for patients who have recovered from PPCM to follow-up with their physician before attempting a subsequent pregnancy. In cases where a patient’s heart has completely recovered and returned to its normal work capacity, a pregnancy may be considered. Regular echocardiograms and stress tests would be administered to ensure the heart is not overstressed.
However, in cases where a patient’s heart failure does not fully recover, a subsequent pregnancy is not recommended as it could cause additional harm to the heart.
If you are diagnosed with postpartum cardiomyopathy, whilst it may be frightening, there are treatments out there that can help you, and you can make a full recovery.
