Peripartum cardiomyopathy - NYSORA

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Peripartum cardiomyopathy

Learning objectives

  • Describe the risk factors and symptoms of peripartum cardiomyopathy
  • Diagnose peripartum cardiomyopathy
  • Manage patients with peripartum cardiomyopathy

Background

  • Peripartum cardiomyopathy (PPCM) is a rare cause of cardiomyopathy occurring during late pregnancy or in the early postpartum period
  • Characterized by significant left ventricular dysfunction and heart failure in the peripartum period in the absence of other identifiable causes of heart failure
  • Potentially life-threatening condition
  • Left ventricle ejection fraction is nearly always less than 45%
  • Etiology is unclear but likely multifactorial (hormonal, inflammatory, genetic,…)

Risk factors

Signs & Symptoms

  • Paroxysmal nocturnal dyspnea
  • Pedal edema
  • Orthopnea
  • Dyspnea on exertion
  • Dry cough
  • Palpitations
  • Increase in abdominal girth
  • Lightheadedness
  • Chest pain
  • Jugular venous distentions
  • Displaced apical impulse
  • Third heart sound
  • Mitral regurgitation murmurs

Diagnosis

  • Diagnosis is based on exclusion
  • Differential diagnoses:
  • Diagnostic tests:
    • Routine blood tests 
      • Evaluate for anemia, electrolyte abnormalities, endocrine conditions, renal or liver dysfunction
      • Brain natriuretic peptide (BNP) is commonly elevated in patients with heart failure and PPCM
    • Chest radiography
      • Cardiomegaly and/or pulmonary edema are suggestive of heart failure but nonspecific to PPCM
    • ECG 
      • Sinus tachycardia, supraventricular tachycardia, ventricular tachycardia, ST segment and T wave abnormalities, dilation of chambers, and QRS prolongation may be observed but are nonspecific
    • Echocardiography
      • Left ventricular ejection fraction <45%: Requirement for PPCM diagnosis
      • Evaluation of other etiologies such as valvular diseases or structural abnormalities
      • Ventricle/atrium dilation and left ventricular thrombus or atrial thrombosis may be present
    • Cardiac MRI
      • Evaluation of other causes of heart failure
    • Cardiac catheterization
      • Only for selected patients
      • Left heart catheterization is indicated in patients with suspected ischemic cardiomyopathy

Management

Management is similar to that of other causes of heart failure

  • Pharmacological
    • Angiotensin-converting enzyme (ACE) inhibitors: First-line treatment postpartum, contraindicated during pregnancy
    • Hydrazaline and nitrate therapy can be used safely during pregnancy
    • Beta-blockers
    • Digoxin (carefully monitor plasma levels)
    • Loop diuretics (e.g., furosemide)
    • Avoid calcium channel blockers and aldosterone antagonists
    • Thromboprophylactic low molecular weight heparin
  • Non-pharmacological:
    • Non-invasive ventilation or intubation
    • Inotropic support
    • Intra-aortic balloon pump, left ventricular assist device or extracorporeal membrane oxygenation may be required in severe cases
    • Heart transplantation in severe cases who do not respond to therapy
    • Implantable defibrillator or cardiac resynchronization in patients with chronic functional impairment

Prognosis

Good prosnosisSmall left ventricular diastolic dimension (less than 5.5cm)
Left ventricular ejection fraction greater than 30% to 35% and fractioning of shortening greater than 20% at the time of diagnosis
Absence of troponin elevation
Absence of left ventricular thrombus
Non-African ethnicity
Poor prognosisQRS greater than 120 ms
Delayed diagnosis
High New York Heart Association (NYHA) class
Multiparity
African descent

Complications

Anesthetic management

peripartum cardiomyopathy, ppcm, ecg, oxygen saturation, blood pressure, icu, hemodynamic monitoring, fluid management, analgesia, catecholamines, systemic vascular resistance, myocardial workload, aorto-caval compression, supine, urterine displacement, epidural, valsalva, myocardial perfusion, cesarean section, vaginal delivery, hypotension, tachycardia, preload, contractility, afterload, neuraxial anesthesia, epidural, spinal, anticoagulation, general anesthesia, opioid, alfentanil, remifentanil, pressor response, laryngoscopy, intubation, inotropes, dobutamine, calcium sensitizers, phosphodiesterase inhibitors, vasopressors, uterotonic medication

Suggested reading

  • Rodriguez Ziccardi M, Siddique MS. Peripartum Cardiomyopathy. [Updated 2022 Jul 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482185/
  • Honigberg MC, Givertz MM. Peripartum cardiomyopathy. BMJ. 2019;364:k5287. Published 2019 Jan 30. doi:10.1136/bmj.k5287
  • Thompson L, Hartsilver E. Peripartum cardiomyopathy. WFSA. https://resources.wfsahq.org/atotw/peripartum-cardiomyopathy/#:~:text=Titrated%20neuraxial%20anaesthesia%2C%20by%20incremental,agents%20that%20reduce%20myocardial%20contractility. Published February 24, 2015. Accessed February 13, 2023. 

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