- PPCM is a form of dilated cardiomyopathy (when the heart chambers enlarge and the cardiac muscle weakens), and is very rare with a high morbidity and mortality rate. PPCM is unique to the pregnant woman, and is defined as cardiac failure that develops between the last month of pregnancy and 5 months postpartum. It is a highly variable condition, and is diagnosed by the absence of an identifiable cause, the absence of recognizable heart disease prior to the last month of pregnancy, and left ventricular systolic dysfunction. It is only diagnosed when no other cause of heart failure is identified . About 1,000 to 1,300 women in the U.S. develop PPCM annually, and it is the most frequent cause of severe complications during pregnancy .
- With PPCM, the heart appears pale and flabby with dilated chambers and is surrounded by interstitial edema (excess fluid). Echocardiography is essential for the diagnosis of this condition. With an echocardiogram, new left ventricular systolic dysfunction will be visualized during the peripartum period .
- Ejection fraction (EF) is reduced with PPCM, usually less than 45%. EF is the amount of blood pumped out by the left ventricle, and normal values typically range between 55-70%. Therefore, a reduced EF signifies poor functioning of the heart and an inadequate supply of oxygen-rich blood going out to the body .
- Many symptoms of heart failure can mimic those of a normal third trimester, so PPCM can be difficult to diagnose. Some of these symptoms are swelling of the feet and legs and shortness of breath. With extreme cases of PPCM, severe shortness of breath and edema persisting after delivery can occur. It is important that during physical exams, doctors asses the lungs for signs of fluid. Lung crackles, rapid heart rate and abnormal heart sounds are signs that PPCM may be present .
Risk factors :
- Increased maternal age
- Multiple pregnancies
- Gestational hypertension
- African race
- History of cardiac disorders
- Feeling of heart racing or skipping beats (palpitations)
- Increased urination during the night (nocturia)
- Shortness of breath with activity and when lying flat
- Swelling of the ankles
- Swollen neck veins
- Low blood pressure, or blood pressure dropping upon standing up.
New York Heart Association Classification System for PPCM :
Class I – Disease with no symptoms
Class II – Mild symptoms or symptoms only with extreme exertion
Class III – Symptoms appear during minimal exertion
Class IV – Symptoms present at rest
The goal is to keep extra fluid from collecting in the lungs and to help the heart recover. Patients are advised to maintain a low-salt diet, restrict fluids, and weigh themselves daily. A weight gain of 3 to 4 pounds or more over 1-2 days may be from fluid buildup. The use of medications fortunately helps most women with PPCM recover normal heart function; however, women that develop severe heart failure will need either mechanical support or a heart transplantation .
Medications typically used :
ACE inhibitors – Help the heart work more efficiently
Beta blockers – These are used to slow the heart rate and increase cardiac recovery time
Diuretics – Reduces fluid retention
Digitalis – Strengthens the pumping ability of the heart
Anticoagulants – Used because patients with PPCM are at increased risk of developing blood clots, especially if their EF is very low.
The heart should return to its normal size and function after pregnancy. If left ventricular dysfunction and symptoms persist however, the woman will still need to be evaluated. These persisting symptoms can also increase a mother’s risk of developing complications with future pregnancies .
- Okeke T, Ezenyeaku C, Ikeako L. Peripartum Cardiomyopathy. Ann Med Health Sci Res. 2013;3(3):313-319. doi:10.4103/2141-9248.117925.
- Peripartum Cardiomyopathy (PPCM). AHA Web site. http://www.heart.org/HEARTORG/Conditions/More/Cardiomyopathy/Peripartum-Cardiomyopathy-PPCM_UCM_476261_Article.jsp#.WZM3l1KWyUl. Updated September 30, 2016. Accessed July, 2017.
- Naderi, S, Raymond R. Pregnancy and heart disease. Dis manag. 2014. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/pregnancy-and-heart-disease/.
- Heart disease and pregnancy: After you are pregnant. Cleveland Clinic Web site. https://my.clevelandclinic.org/health/articles/heart-disease-pregnancy/after. Updated November, 2015. Accessed July, 2017.
By: Stephanie Kramer