Successful pregnancy 5 years after cardiac transplantation for peripartum cardiomyopathy

Severe cardiac disease in pregnancy, part II: impact of congenital and acquired cardiac diseases during pregnancy

PURPOSE OF REVIEW

Part II of this review gives an overview of the different maternal cardiac problems during pregnancy and their management, and developments over recent years.

RECENT FINDINGS

Many studies published over the last 5 years provided new insights on different cardiac diseases in pregnancy. Publications discussed in this part of the review on cardiac disease in pregnancy, for example, provide epidemiological data on heart disease during pregnancy in general, and cardiomyopathy and ischemic heart disease in particular. In addition, we discussed the implications of a history of peripartum cardiomyopathy for a subsequent pregnancy, interventional strategies during pregnancy in women with ischemic heart disease, and the role of echocardiography in the evaluation of cardiac disease in pregnancy.

SUMMARY

The prevalence of the different causes of heart disease has shifted towards congenital heart disease by the end of the millennium. In developing countries, relatively rare diseases like rheumatic fever are still common, so these diseases are increasingly 'exported' to developed countries. The group of women with congenital heart disease represents most women with heart disease during pregnancy, followed by rheumatic heart disease. With the exception of patients with Eisenmenger's syndrome, pulmonary vascular obstructive disease, and Marfan's syndrome with aortopathy, maternal death during pregnancy is rare in women with heart disease. Although the risk for mortality is low in pregnant women with preexistent cardiac disease, these women are at increased risk for serious morbidity such as heart failure, arrhythmias, and stroke.

Pregnancy in heart transplant recipients

The aim of this report is to present data from Italian cardiac transplant centers assessing pregnancy after cardiac transplantation. Our retrospective survey included 10 pregnancies occurring in 7 patients during January 1991 to February 2002. Eight pregnancies were completed successfully and 2 abortions were reported (frequency rate 20%). No complications were observed during pregnancy or after delivery. Of 8 infants studied, 6 (75%) were born at term and 2 (25%) pre-term. One baby presented congenital talipes valgus. Pediatric development was uneventful. The data from the literature and our series show that a multidisciplinary approach is mandatory. The course of pregnancy is usually normal and the maternal and fetal outcomes are usually favorable. Although no fetal malformations have been reported, prolonged follow-up of these infants is required.

Peripartum cardiomyopathy

The diagnosis of peripartum cardiomyopathy should be considered whenever women present with heart failure during the peripartum period. This cardiomyopathy is distinguished by rapid onset, occurrence in the peripartum period, and significant improvement in up to 50% of affected women. The cause and pathogenesis of this dilated cardiomyopathy remain unknown. Treatment is similar to medical therapy for other forms of dilated cardiomyopathy. Worsening of heart failure may require management in the ICU with support by vasodilators, inotropes, and ventricular assist devices. Patients with severe ventricular dysfunction are less likely to survive and recover normal cardiac function. Subsequent pregnancies may provoke a recurrence, even in patients who apparently recover.

Peripartum cardiomyopathy: a condition intensivists should be aware of

We use an illustrative case of severe peripartum cardiomyopathy with congestive heart failure to introduce this topic and proceed to cover its pathophysiology, incidence, management and outcome.