Pocket ObGyn – Peripartum Cardiomyopathy
See Abbreviations
Definition and Epidemiology
- Heart failure w/i the last month of Preg to 5 mo postpartum
- Diagnostic criteria based on risk for idiopathic DCM (Obstet Gynecol 1999;94:311): Absence of prior heart dz; no alternative cause; echocardiographic evid of LV dysfxn (EF
<45% or fractional shortening <30%, LVED dimension > 2.7m2)
- Incid 1 in 3000–4000 live-births (JAMA 2000;283:1183); risk w/ multiparity & age
Pathophysiology
- Cause unk; dev of pulm edema 2/2 LV dilation & dysfxn
Clinical Manifestations and Diagnostic Studies
- S/sx of pulm edema: Dyspnea, cough, orthopnea, tachy, hemoptysis, elevated JVP, S3 present
- CXR: Cardiomegaly, pulm edema, pleural effusions
- ECG: Look for Afib, bundle branch block
- Echocardiogram: LV dilation, ¯ EF, regional or global LV HK, poss RV HK, poss mural thrombi
Treatment
- b-blockers improve cardiac fxn & survival in stable, euvolemic pts
- OK to use implantable defibrillators in Preg (Circulation 1997;96:2808)
Labor and Delivery Management
- Pain control w/ epidural: ¯ cardiac work & ¯ tachy
- Cesarean for obstetric indications only
Prognosis
- Peripartum: Mortality 6–10%; cardiac xplantation 4–7% (Circulation 2005;111(16):2050; N Engl J Med 2000;342(15):1077); w/i 6 mo, ½ of pts demonstrate resolution of LV dilation
® good prog, the other ½ ® 85% 5-y mortality
- Subseq Preg: Recurrence up to 50% (Circulation 1995;92 (Suppl 1):1; N Engl J Med
2001;344(21):1567; Ann Intern Med 2006;145(1):30)
>8% mortality if LV dysfxn has not resolved ® discourage Preg; <2% mortality if LV dysfxn has resolved
| Management of peripartum cardiomyopathy | |
| Goal | Drug |
| ¯ preload | Diuretic |
| ¯ afterload | Hydralazine (antepartum), ACEI (postpartum) |
| Relieve pulm congestion | Diuretic |
| contractility | Dig |
| Rate control w/ AF | Dig |
| Anticoagulation | Heparin/LMWH (antepartum), warfarin (postpartum) |