Why Do Some Recovered Peripartum Cardiomyopathy Mothers Experience Heart Failure With a Subsequent Pregnancy?

Outcomes of subsequent pregnancy in women with peripartum cardiomyopathy: a systematic review and meta-analysis

INTRODUCTION

The primary concern for women who have experienced peripartum cardiomyopathy (PPCM) is the safety of a subsequent pregnancy (SSP). To maximie decision-making, facilitate effective patient counselling, and ultimately improve maternal and fetal outcomes as a whole, it is critical to comprehend the outcomes of SSP in women who have previously experienced PPCM. This study aimed to evaluate the outcomes of SSP in women with PPCM.

METHODS

Three databases (PubMed, Scopus, and ScienceDirect) were used to identify relevant studies prior to 17 October 2023. A total of 662 studies were reviewed. Following the abstract and full-text screenings, 18 observational studies were included, out of which 2 were deemed suitable for inclusion in this meta-analysis. The quality assessment was conducted using the Newcastle-Ottawa Scale.

RESULTS

This study has a total of 487 SSPs. Although recovered left ventricular (LV) function before entering SSP has the potential to be a beneficial prognostic factor, recovered LV function still has a substantial risk of relapse. The mortality rate of PPCM in an SSP ranged from 0% to 55.5%. Persistent LV dysfunction was significantly associated with an increased mortality rate (OR 13.17; 95% CI 1.54 to 112.28; p=0.02) and lower LV ejection fraction (MD -12.88; 95% CI -21.67 to -4.09; p=0.004). Diastolic and right ventricular functions remained unchanged before SSP and at follow-up. The majority of the SSP was observed alongside hypertension, while pre-eclampsia emerged as the predominant hypertensive complication in most studies.

CONCLUSION

SSP increases the risk of relapse and mortality in women with a previous history of PPCM. Persistent LV dysfunction prior to the SSP has a higher mortality risk compared with recovered LV function. SSP was also associated with the worsening of LV echocardiography parameters.

A disease of her own? Unique features of heart failure in women

Heart failure (HF) is a significant and growing public health challenge for women. Compared with men, women tend to develop HF later in life and are more likely to experience HF with preserved ejection fraction. There are also significant sex differences in outcomes, with women reporting lower quality of life but overall better survival versus men. In this review, we summarize sex differences in traditional HF risk factors, such as hypertension, diabetes, obesity and coronary artery disease, as well as female-specific HF risk factors including menopause, pregnancy and adverse pregnancy outcomes, and breast cancer therapy. While our understanding of the sex-specific efficacy of HF therapy remains limited by the underrepresentation of women in major clinical trials, there is a suggestion of preferential benefit of specific agents for women. Further work is required to better understand the pathophysiology of HF in women uniquely and to increase representation of women in clinical trials.

Contemporary outcome of subsequent pregnancies in patients with previous peripartum cardiomyopathy

AIMS

To describe the effect of subsequent pregnancies (SSP) on left ventricular (LV) function and outcomes in patients with peripartum cardiomyopathy (PPCM).

METHODS

Among146 women with PPCM who were prospectively followed at two medical centres in Israel (2007-2019), 75 SSPs (in 50 women) were identified: 8 miscarriages, 8 terminations, and 59 life birth.

RESULTS

Forty-five patients with 59 full-term SSPs [mean age was 32.9 ± 4.1 years, LV ejection fraction (LVEF) 57.7 ± 5.1%] were analysed. Data on LVEF at 1-month post-delivery were available in 46 and at 6 months in 36 SSPs. There was a small decrease in the mean LVEF, mostly at third trimester (57.2 ± 5.6 vs. 54.4. ± 7.3, P < 0.001); and at 1-mont (57.9 ± 5.7% vs. 55.4 ± 6.1%, P = 0.001) and at 6-month post-delivery (57.4 ± 6.1 vs. 55.3 ± 7.9%, P = 0.03). In patients with pre-SSP LV LVEF ≥55%, a mild reduction in the mean group LVEF was seen at 1-month post-delivery (P = 0.009). One patient with pre-SSP LVEF ≥55% developed severe relapse. In patients with pre-SSP LVEF <55%, a mild reduction in LVEF was obtained mostly at third trimester (51.1 ± 5.6 vs 47.0 ± 7.4%, P < 0.001), which persisted at 6 months (P = 0.03). A relapse was observed in three (25%) women with LVEF <55%. There was no maternal mortality, 32 patients delivered by caesarean section, and there were no foetal complications.

CONCLUSIONS

Our study indicates a favourable outcome and low likelihood of maternal mortality associated with SSP in women with a history of PPCM and recovered LV systolic function. SSP was associated with a slight reduction in LVEF mostly during the third trimester, which persisted up to 6 months after delivery.

Peripartum Cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a form of heart failure that occurs toward the end of pregnancy or in the months following pregnancy and is marked by left ventricular systolic dysfunction. The cause of PPCM remains unknown and there is no diagnostic test specific to PPCM. Outcomes vary and include complete left ventricular recovery, persistent cardiac dysfunction, transplant, and death. Numerous advances have been made in understanding this disease, but many knowledge gaps remain. This article reviews recent data and recommendations for clinical practice in addition to highlighting the multiple knowledge gaps related to PPCM that warrant further investigation.

Peripartum Cardiomyopathy Incidence, Risk Factors, Diagnostic Criteria, Pathophysiology, and Treatment Options

Peripartum cardiomyopathy is a rare and a severe form of heart failure that affects women during pregnancy or shortly after delivery. Risk factors include advanced age, race, multiparity, multifetal pregnancy, socioeconomic disparity, and medical comorbidities including systemic hypertension, diabetes, asthma, and anemia. Peripartum cardiomyopathy is associated with increased morbidity and mortality, as well as a detrimental long-term impact on quality of life. Its etiology is not clear, although it is thought to be a combined effect of a hyperdynamic fluid state associated with pregnancy, hormonal changes unique to gestation, and a genetic predisposition. There is no current expert consensus on an optimal treatment regimen. This article will provide a comprehensive review and update on this important disease state.

Unveiling the Mystery of Peripartum Cardiomyopathy: A Traditional Review

Peripartum cardiomyopathy (PPCM) can be classified as a variant of dilated cardiomyopathy identified usually within the first five months of delivery or during the last month of pregnancy. This condition presents as systolic heart failure. PPCM affects thousands of women in the United States each year. Even though it was first noticed in the 1800s, its etiology remains unknown. This study aims to review the pathophysiology and management of PPCM and explore the possible outcomes of peripartum cardiomyopathy. PPCM can lead to maternal death if diagnosis or treatment is delayed. Diagnosing PPCM has been challenging because it can be misdiagnosed or perceived as a sign of pregnancy since most of the symptoms of PPCM strongly match those within the typical pregnancy continuum and postpartum cycle. Patients' implications are fatal and carry a high mortality rate when PPCM is misdiagnosed or treatment is delayed. To accurately identify PPCM, using echocardiography, the left ventricular end-diastolic size and the ejection fraction should be measured to determine the severity of PPCM. Managing peripartum cardiomyopathy involves using traditional treatments for heart failure. Therapeutic recommendations are made depending on the patient's status (pregnancy, breastfeeding, postpartum) while considering the drug-safety profiles before administration. Some other treatments have also been used to control PPCM depending on how severe it has become; for example, antiarrhythmics have been used to treat cardiac arrhythmias when they ensue. In extreme cases, mechanical assistance and transplantation could be required. Based on the proposed pathophysiology involving the 16kDA anti-angiogenic sub-fragment, bromocriptine may be used even though it still needs more assessment due to limited evidence.

Using PubMed as a major search resource, a thorough analysis of publications was carried out after incorporating this review's inclusion and exclusion criteria. A total of 455,141 publications were found using keywords and keyword combinations. With a careful selection of articles, 31 publications provided relevant information on our primary endpoint. All articles in this examination were chosen without limitation to the type of study, including clinical trials, review articles, meta-analyses, and so on. Our review suggests that, based on factors such as early detection and management, disease severity, ethnicity, and quality of patient care, patients with PPCM presented different outcomes and prognosis. However, despite PPCM's high mortality rate and its risk of recurrence, most patients tend to recover within six months of disease onset.

Irreversible Acquired Noncompaction Cardiomyopathy in a Parturient with Corrected Atrial Septal Defect: A Case Report and Clinical Implications

Left ventricular noncompaction (LVNC) is described as a cardiomyopathy with an increase in left ventricle trabeculations and recesses. We report a rare case of persistent pregnancy-acquired LVNC cardiomyopathy and review the anesthetic peripartum management strategies. A 33-year-old parturient was followed closely by the high-risk obstetric service for her second pregnancy. She had an unresolved LVNC cardiomyopathy that was diagnosed during her first pregnancy for which she had a caesarean section. Her symptoms included occasional palpitations and dyspnea. She was started on metoprolol and enoxaparin. A successful caesarean section was performed at 37 weeks gestation under regional anesthesia. Echocardiograms prior to and during the second pregnancy demonstrated persistence of the LV hypertrabeculations, LV systolic dysfunction, and a left ventricular ejection fraction (LVEF) of 35%. Pregnancy-induced LV hypertrabeculations occur in a significant proportion of women, but most cases spontaneously resolve completely. Favorable maternal and fetal outcomes require multidisciplinary care and careful selection of the anesthetic technique and drugs that maintain stable hemodynamics.

Subsequent reproductive outcome among women with peripartum cardiomyopathy: a nationwide study

OBJECTIVE

To describe the subsequent reproductive outcome for a Danish nationwide cohort of women with peripartum cardiomyopathy (PPCM).

DESIGN

Nationwide historic cohort study.

SETTING

Secondary and tertiary centres across Denmark.

SAMPLE

Women with PPCM.

METHODS

Sixty-one women with PPCM during 2005-2014 were identified in a nationwide, registry-based study and the diagnosis was validated through audit of patient records. A new search for subsequent reproductive outcome in this cohort from 2005-2016 was conducted in the Danish National Birth Registry and the Danish National Patient Registry. Detailed clinical data were obtained from patient records.

MAIN OUTCOME MEASURES

Sterilisations and subsequent reproductive outcomes after PPCM, including all pregnancies, miscarriages, terminations and deliveries.

RESULTS

Of 61 women with PPCM, 13 (21%) had a total of 16 subsequent pregnancies resulting in one miscarriage, seven early terminations, one ectopic pregnancy and seven liveborn children. There were no maternal deaths or significant cardiac events during pregnancy, but one woman, who gave birth to a liveborn child, had a relapse of PPCM 7 weeks postpartum. None of the six women who had a first trimester termination, experienced relapse of PPCM. Of the 13 women with a subsequent pregnancy, 62% had prior to this been advised against a new pregnancy due to the risk of recurrent PPCM. A total of four women (6.6%) were sterilised.

CONCLUSION

Peripartum cardiomyopathy affects women's reproduction with few subsequent pregnancies resulting in a liveborn child. The finding of a 1/7 relapse among women with recovered LVEF is in accordance with most previous studies.

TWEETABLE ABSTRACT

Outcome in pregnancies after peripartum cardiomyopathy: results from the first nationwide study.

Peripartum Cardiomyopathy

Peripartum cardiomyopathy is a potentially life-threatening pregnancy-associated disease that typically arises in the peripartum period and is marked by left ventricular dysfunction and heart failure. The disease is relatively uncommon, but its incidence is rising. Women often recover cardiac function, but long-lasting morbidity and mortality are not infrequent. Management of peripartum cardiomyopathy is largely limited to the same neurohormonal antagonists used in other forms of cardiomyopathy, and no proven disease-specific therapies exist yet. Research in the past decade has suggested that peripartum cardiomyopathy is caused by vascular dysfunction, triggered by late-gestational maternal hormones. Most recently, information has also indicated that many cases of peripartum cardiomyopathy have genetic underpinnings. We review here the known epidemiology, clinical presentation, and management of peripartum cardiomyopathy, as well as the current knowledge of the pathophysiology of the disease.

Women's Experiences Being Diagnosed With Peripartum Cardiomyopathy: A Qualitative Study

INTRODUCTION

Cardiovascular disease has been identified as the leading cause of maternal mortality in the United States, with cardiomyopathy, including peripartum cardiomyopathy (PPCM), accounting for 12% to 16% of all pregnancy-related deaths. The purpose of this study was to describe women's experiences being diagnosed with PPCM.

METHODS

This investigation was conducted using a qualitative design. We collected publicly available narratives posted by 92 women with PPCM (mean [SD] age 29 [6] years, mean [SD] ejection fraction 25.5 [10.8]%) in 3 online support groups. Data were coded and thematically organized so as to produce a richly detailed account of this experience.

RESULTS

The experience of diagnosis was marked by the women's distinct memories of their initial symptoms and whether they were dismissed or taken seriously. The most commonly reported symptoms were extreme shortness of breath, orthopnea, tachycardia, palpitations, chest pain, cough, and edema. Nearly 40% of women experienced symptom dismissal by health care providers. One-fourth of women were initially given inaccurate diagnoses ranging from "new mom anxiety" to asthma. Women described their initial reaction to diagnosis as feeling terrified, devastated, and feeling a sense of doom. Women had difficulty caring for their newborns during the postpartum period, and they struggled with the medical advice they received to not get pregnant again.

DISCUSSION

Despite experiencing severe subjective and objective symptoms, nearly 40% of women with PPCM experienced symptom dismissal by health care providers, in part due to the overlap between normal symptoms of pregnancy or the postpartum period and symptoms of heart failure.

Peripartum Cardiomyopathy: Current Knowledge and Future Directions

Peripartum cardiomyopathy is a form of heart failure occurring at the end of pregnancy or early in the postpartum period. Women may recover, have persistent cardiac dysfunction or suffer complications and death. Women who are African-American, older, hypertensive or have multiple gestation pregnancies have increased risk. Diagnosis and treatment may be delayed due to similarities between symptoms of normal pregnancy and heart failure. Echocardiography is essential for the diagnosis, and B-type natriuretic peptide can be helpful. Treatment for systolic heart failure must be adjusted during pregnancy, and anticoagulation may be indicated. Even after recovery, subsequent pregnancy confers substantial risk of worsening heart failure. Further investigations into the etiology, duration of treatment and risks for relapse are needed.

Discoveries in peripartum cardiomyopathy

The past decade has seen remarkable gains for outcomes in peripartum cardiomyopathy (PPCM), one of the leading causes of maternal mortality and morbidity in the USA and many other countries, including the high-incidence areas of Haiti and South Africa. This review article emphasizes the importance of continuing the process of increasing awareness of PPCM and presents details of this evolving picture, including important discoveries that point the way to full recovery for almost all PPCM subjects. In addition, new interventions will be highlighted, which may facilitate recovery. Numerous studies have demonstrated that when the diagnosis of PPCM is made with LVEF > 0.30, the probability is that recovery to LVEF ≥ 0.50 will occur in the overwhelming majority of subjects. PPCM patients diagnosed with severely depressed systolic function (LVEF < 0.30) and a remodeled left ventricle with greater dilatation (LVEDd ≥ 60mm) are least likely to reach the outcome recovery goals. These are the patients with the greatest need for newer interventional strategies.