Peripartum cardiomyopathy: current management and future perspectives

Abstract

Pregnancy is associated with marked physiological changes challenging the cardiovascular system. Among the more severe pregnancy associated cardiovascular complications, peripartum cardiomyopathy (PPCM) is a potentially life-threatening heart disease emerging towards the end of pregnancy or in the first postpartal months in previously healthy women. A major challenge is to distinguish the peripartum discomforts in healthy women (fatigue, shortness of breath, and oedema) from the pathological symptoms of PPCM. Moreover, pregnancy-related pathologies such as preeclampsia, myocarditis, or underlying genetic disease show overlapping symptoms with PPCM. Difficulties in diagnosis and the discrimination from other pathological conditions in pregnancy may explain why PPCM is still underestimated. Additionally, underlying pathophysiologies are poorly understood, biomarkers are scarce and treatment options in general limited. Experience in long-term prognosis and management including subsequent pregnancies is just beginning to emerge. This review focuses on novel aspects of physiological and pathophysiological changes of the maternal cardiovascular system by comparing normal conditions, hypertensive complications, genetic aspects, and infectious disease in PPCM-pregnancies. It also presents clinical and basic science data on the current state of knowledge on PPCM and brings them in context thereby highlighting promising new insights in diagnostic tools and therapeutic approaches and management.

Keywords: Heart failure; Peripartum cardiomyopathy; Pregnancy.

Figure 1

(A) Time course of LVEF in a peripartum cardiomyopathy patient (37 years, 3 Gravida, 3 Para) with severe peripartum cardiomyopathy after delivery of her second child and her subsequent pregnancy. Fast improvement of cardiac function and symptoms on immediate treatment with standard heart failure therapy and bromocriptine on index peripartum cardiomyopathy (BR: 5 mg/day for 2 months). The LVEF was still impaired when entering the subsequent pregnancy 8 months later. During pregnancy, the patient was treated with β-blocker occasionally supported by diuretics and further improvement of her condition in the first two trimesters was observed. A moderate decline of cardiac function in the third trimester occurred promoting Cesarean-section in week 36 followed by full standard heart failure therapy and bromocriptine (BR: 5 mg/day for 2 months) and subsequent improvement of cardiac function. Images of echocardiographic examinations shortly after onset of index peripartum cardiomyopathy (B), before subsequent pregnancy (C), shortly after subsequent delivery (D), and at 1-month-follow-up (E).