Peripartum cardiomyopathy: a review of the literature

The Relationship Between Peripartum Cardiomyopathy and Preeclampsia – Pathogenesis, Diagnosis and Management

Peripartum cardiomyopathy (PPCM) is a condition with an incompletely understood etiology, although many risk factors for this disorder have been mentioned. Preeclampsia (PE) is a rare but undoubtedly very important cause of PPCM. Early recognition and prompt treatment of preeclampsia and peripartum cardiomyopathy are essential to optimize pregnancy outcomes. An extensive manual search of major electronic databases was conducted in November 2021. The following literature review provides a comprehensive discussion of peripartum cardiomyopathy and preeclampsia and quantifies the prevalence of PE in women with PPCM. The authors highlighted aspects such as epidemiology, risk factors, cardiovascular changes, diagnosis and clinical presentation, and management and complications. Accumulating data indicate that both conditions have a similar pathogenesis characterized by vascular abnormalities. In both conditions we can observe an increase in interleukin-6 and gamma interferon, CCL2/MCP1, and decreased SOD activity. sFLT1 (a soluble form of fms-like tyrosine kinase 1), a substance with antiangiogenic and probably cardiotoxic effects, may be important. Preeclampsia and peripartum cardiomyopathy are characterized by recurrence rates that follow a similar pattern in subsequent pregnancies, and mortality remains a concern. Our analysis highlights the need to better understand the co-morbidity of PE and PPCM, and the need to qualify patients for the same clinical trials because of the common origin of these conditions.

Peripartum cardiomyopathy: a global effort to find the cause and cure for the rare and little understood disease

In this review, we present our current understanding of peripartum cardiomyopathy (PPCM) based on reports of the incidence, diagnosis and current treatment options. We summarise opinions on whether PPCM is triggered by vascular and/or hormonal causes and examine the influence of comorbidities such as preeclampsia. Two articles published in 2021 strongly support the hypothesis that PPCM may be a familial disease. Using large cohorts of PPCM patients, they summarised the available genomic DNA sequence data that are expressed in human cardiomyocytes. While PPCM is considered a disease predominately affecting the left ventricle, there are data to suggest that some cases also involve right ventricular failure. Finally, we conclude that there is sufficient evidence to warrant an RNAseq investigation and that this would be most informative if performed at the cardiomyocytes level rather than analysing genomic DNA from the peripheral circulation. Given the rarity of PPCM, the combined resources of international human heart tissue biobanks have assembled 30 ventricular tissue samples from PPCM patients, and we are actively seeking to enlarge this patient base by collaborating with human heart tissue banks and research laboratories who would like to join this endeavour.

An anaesthetic quandary: Caesarean section during cardiac failure in a case of peripartum cardiomyopathy complicated by preeclampsia

Anaesthetic management of cardiac disorders in pregnancy has always been complicated and challenging. A rare but extremely fatal entity, peripartum cardiomyopathy (PPCM) is a life-threatening disease affecting the parturient with mortality rates as high as 35–50%. Developing in late pregnancy or immediately after delivery, this unique disorder endangers not only the mother but the baby as well. We report here a case of a 28-year-old female parturient presenting at 37 weeks of gestation for caesarean delivery with recently diagnosed peripartum cardiomyopathy (ejection fraction of 28%) complicated by severe preeclampsia. She developed cardiac failure just before the induction of anaesthesia. She was successfully resuscitated, operated under general anaesthesia and shifted to the critical care unit for further management.

Maternal and fetal prognosis of subsequent pregnancy in black African women with peripartum cardiomyopathy

Background

The aim of this study was to describe maternal and fetal outcomes after pregnancy complicated by peripartum cardiomyopathy (PPCM).

Methods

We included women that had subsequent pregnancy (SSP) after PPCM and assessed maternal prognosis and pregnancy outcomes, in-hospital up to one week after discharge. Clinical and echocardiographic data were collected comparing alive and deceased women. Factors associated with pregnancy outcomes were assessed.

Results

Twenty-nine patients were included, with a mean age of 26.7 ± 4.6 years and a mean gravidity number of 2.3 ± 0.5 of. At the last medical control before subsequent pregnancy, there was no congestive heart failure, the mean left ventricular diastolic diameter (LVDD) was 53 ± 4 mm and the left ventricular ejection fraction (LVEF) was ≥50% in 13 cases (44.8%).

Maternal outcomes were marked by 14 deaths (48.3%). Among the factors tested in univariate analysis, LVEF at admission had an excellent receiver-operating characteristic (ROC) curve to predict maternal mortality (AUC = 0.95; 95% CI 0.87–1, p < 0.001), with a cut off value of < 40% (sensitivity = 93% and specificity = 87%). Concerning fetal outcomes, baseline LVEF had the best area under the curve (AUC) to predict abortion or prematurity among all variables (AUC = 0.75; 95% CI 0.58–092, p = 0.003), with a cut-off value of < 50% (sensitivity = 79%, specificity = 67%).

Conclusions

SSP outcomes are still severe in our practice. Maternal mortality remains high and is linked to ventricular systolic function at admission (due to pregnancy), while fetal outcomes are linked to baseline LVEF before pregnancy.

Cardiac arrest in a case of undiagnosed dilated cardiomyopathy patient presenting for emergency cesarean section

Cardiac diseases in the pregnancy pose a multitude of challenges to the obstetricians as well as anesthesiologists. Cardiac pregnant patients presenting for emergency cesarean section do not give time for cardiac optimization and stabilization if they come to the hospital for the first time without any antenatal check-up. The situation can get worse if there is no history related to the decompensated cardiac tissue with asymptomatic gestation and also if the relatives hide all the facts from the doctor about any past cardiac history. We report a case of term pregnancy for emergency cesarean section with asymptomatic dilated cardiomyopathy, which developed severe ventricular arrhythmias and cardiac arrest during the surgical procedure. She was resuscitated successfully on the operation table and was shifted to Intensive Care Unit for further management. The diagnosis of dilated cardiomyopathy was made only after carrying out echocardiography in the postoperative period. The history of previous cardiac complaints was not revealed purposefully by the relatives to avoid the expenses which they would have incurred on investigations and treatment of cardiac ailment.

[Special features of peripartum cardiomyopathy in Africa: the case of Togo on a prospective study of 41 cases at Sylvanus Olympio University Hospital of Lome]

Introduction

La cardiomyopathie du péripartum (CMPP) est une défaillance cardiaque dont l’étiologie demeure encore méconnue.

Méthodes

Il s'agit d'une étude prospective descriptive réalisée dans le service de cardiologie du CHU Sylvanus olympio de Lomé du 1er janvier 2010 au 30 avril 2012. Elle a concerné 41 patientes ayant présenté une insuffisance cardiaque entre le 8eme mois de la grossesse et les 5 premiers mois du post-partum.

Résultats

L’âge moyen des patientes était de 31,47 ans (extrêmes 21 et 44ans). L'incidence de la CMPP était de 1/362 grossesses. La parité moyenne était de 3,07 (extrêmes 1 et 6). Les symptômes étaient apparus dans le post-partum dans 90,24% des cas. Un retard important de diagnostic était observé. L'insuffisance cardiaque globale était le mode de décompensation dans 65,85%. Les signes électrocardiographiques étaient essentiellement la tachycardie sinusale (97,56%) et l'hypertrophie ventriculaire gauche (97,56%). L’échographie cardiaque a montré dans tous les cas une cardiomyopathie dilatée. Quatre cas de thrombus intraventriculaire gauche étaient notés. La FEVG était sévèrement altérée. L'HTAP était importante dans 56,09%.

Conclusion

La cardiomyopathie du péripartum est une complication cardiaque grave de la grossesse de cause inconnue, fréquente dans la population africaine.

Peripartum cardiomyopathy - case series

OBJECTIVES

To study the pattern of presentation, course of disease and outcome of pregnancy in Peripartum Cardiomyopathy.

METHODS

A prospective study of sixteen cases of PPCM was conducted at Apple Saraswati Multispecialty Hospital and Dr. D.Y. Patil Medical College and Hospital, Kolhapur, Maharashtra, India from January 2006 to December 2012. Data included age distribution, parity, gestational age, symptoms and risk factors. Medical management and pregnancy outcome were documented. Serial echocardiography data was compiled for a period of one year.

RESULTS

In our study 9/16 (56%) were primigravidae, 4/16 (25%) had pre-eclamsia and 6/16 (35%) had co-existing hypertension. The difference in Echocardiography parameters observed between recovered and non-recovered patients was significant: Left Ventricular End diastolic dimension (5.6 cm vs 6.06 cm), Left Ventricular Ejection Fraction (28.7% vs 22.4%) and Left Ventricular fractional shortening (17.5% vs 13.4%). Thirteen out of sixteen patients were followed up for a period of one year out of which 61% (8/13) patients recovered completely. There was one mortality.

CONCLUSION

PPCM is a diagnosis of exclusion. Majority were young primigravidae presenting postnatally. Pre-eclampsia and hypertension were risk factors. ECHO parameters were reliable predictors of recovery. Future pregnancies are better avoided.

Peripartum cardiomyopathy: a contemporary review

Peripartum cardiomyopathy is a rare and potentially fatal disease. Though approximately half of the patients recover, the clinical course is highly variable and some patients develop refractory heart failure and persistent left ventricular systolic dysfunction. It is diagnosed when women present with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. Etiology remains unclear, and treatment is similar to other cardiomyopathies and includes evidence-based standard heart failure management strategies. Experimental strategies such as intravenous immunoglobulin and bromocriptine await further clinical validation.

Pregnancy with dilated and peripartum cardiomyopathy: maternal and fetal outcome

BACKGROUND

A retrospective review of the records of all the patients of dilated cardiomyopathy (DCM) with pregnancy at PGIMER, Chandigarh, India, in order to find out maternal and fetal outcome.

MATERIALS AND METHODS

We did a retrospective analysis of records of diagnosed cases of DCM from 1994 to 2010. There were records of 38 patients who had DCM with pregnancy. Detailed history was followed by systemic examination, routine investigations and echocardiography. Multidisciplinary care was given to these women by obstetrician, cardiologist, anesthetist and neonatologist. Pharmacotherapy consisted to diuretics, alpha and beta blockers and heparin or low-dose aspirin for thrombo prophylaxis. Elective induction of labor was advised after 37 weeks of gestation subject to favorability of cervix.

RESULTS

Out of 1,472 patients of heart disease during study period, 38 women had DCM. Out of these, 8 (21 %) had idiopathic cardiomyopathy, two had DCM due to thyrotoxicosis and 28 (73.6 %) patients had peripartum cardiomyopathy. Mean gestational age at the time of presentation was 35 weeks. Majority of the patients (19/38) presented with complaints of exertional dyspnoea. Mean LVEF at the time of diagnosis was 32.28 %. There were six (15.8 %) maternal deaths and all of them had global hypokinesia on echocardiography and presented in NYHA class IV. Fetal outcome too depended upon maternal cardiac status. There were eight stillbirths and all the patients who had IUFD belonged to class IV. Twelve patients (40 %) had preterm delivery. Mean birth weight of babies was 2 kg.

Ischemic Stroke during Pregnancy and Puerperium

Ischemic stroke during pregnancy and puerperium represents a rare occurrence but it could be a serious and stressful event for mothers, infants, and also families. Whenever it does occur, many concerns arise about the safety of the mother and the fetus in relation to common diagnostic tests and therapies leading to a more conservative approach. The physiological adaptations in the cardiovascular system and in the coagulability that accompany the pregnant state, which are more significant around delivery and in the postpartum period, likely contribute to increasing the risk of an ischemic stroke. Most of the causes of an ischemic stroke in the young may also occur in pregnant patients. Despite this, there are specific conditions related to pregnancy which may be considered when assessing this particular group of patients such as pre-eclampsia-eclampsia, choriocarcinoma, peripartum cardiomiopathy, amniotic fluid embolization, and postpartum cerebral angiopathy. This article will consider several questions related to pregnancy-associated ischemic stroke, dwelling on epidemiological and specific etiological aspects, diagnostic issue concerning the use of neuroimaging, and the related potential risks to the embryo and fetus. Therapeutic issues surrounding the use of anticoagulant and antiplatelets agents will be discussed along with the few available reports regarding the use of thrombolytic therapy during pregnancy.

Dyspnoea at term in an obese mother

Peripartum cardiomyopathy is a serious, potentially life-threatening heart disease of uncertain aetiology in previously healthy women. We report a morbidly obese woman who presented with peripartum shortness of breath. We discuss the differential diagnosis of dyspnoea in pregnancy and highlight the complexity of care of the morbidly obese woman.

Combined epidural anesthesia and ultrasound guided peripheral nerve block for wound revision in a patient with peripartum cardiomyopathy -A case report-

Peripartum cardiomyopathy (PPCM) is a rare complication that occurs between the late stage of pregnancy and six months after delivery. PPCM presents as symptoms of left ventricular dysfunction and it can be fatal unless treated promptly. Furthermore, anesthesia and surgery in such patients is a large challenge to anesthesiologists. First and foremost, the maintenance of stable hemodynamics is a major concern. We report a case of combined lumbar epidural anesthesia and both ilioinguinal and iliohypogastric nerve block under ultrasound guided for a wound revision in a 37-year-old woman diagnosed with PPCM after an emergency cesarean section.

Rheumatologic manifestations of pregnancy

Pregnancy, whether normal or complicated, induces change in nearly every system of the body. Because most rheumatologic disorders are multisystemic and often affect young women, it may be difficult to differentiate pregnancy-related change from new onset or exacerbation of rheumatic disease. Familiarity with common manifestations of pregnancy is important in evaluating young women of childbearing age,whether or not they have known rheumatologic disease. Presentation of new connective tissue disease during pregnancy is often associated with poorer prognosis, so it is especially important to distinguish between pregnancy-induced change and true autoimmune inflammation requiring prompt and aggressive therapy.

The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs

Since 2006, the Canadian Cardiovascular Society heart failure (HF) guidelines have published annual focused updates for cardiovascular care providers. The 2010 Canadian Cardiovascular Society HF guidelines update focuses on an increasing issue in the western world - HF in ethnic minorities - and in an uncommon but important setting - the pregnant patient. Additionally, due to increasing attention recently given to the assessment of how care is delivered and measured, two critically important topics - disease management programs in HF and quality assurance - have been included. Both of these topics were written from a clinical perspective. It is hoped that the present update will become a useful tool for health care providers and planners in the ongoing evolution of care for HF patients in Canada.

Peripartum cardiomyopathy: a current review

Peripartum cardiomyopathy (PPCM) is a rare but potentially lethal complication of pregnancy occurring in approximately 1 : 3,000 live births in the United States although some series report a much higher incidence. African-American women are particularly at risk. Diagnosis requires symptoms of heart failure in the last month of pregnancy or within five months of delivery in the absence of recognized cardiac disease prior to pregnancy as well as objective evidence of left ventricular systolic dysfunction. This paper provides an updated, comprehensive review of PPCM, including emerging insights into the etiology of this disorder as well as current treatment options.

Successful treatment of peripartum cardiomyopathy with extracorporeal membrane oxygenation

A 24-year-old female developed heart failure within four months of delivering her first child. Echocardiogram revealed a moderately dilated left ventricle with severely reduced systolic function. She continued to decompensate, requiring intubation and inotropic support. When the use of an intra-aortic balloon pump failed to stabilize the patient, the decision was made to place her on ECMO. The circuit consisted of a Quadrox D membrane oxygenator and a CentriMag® centrifugal pump. After 11 days of support, the patient met the weaning criteria and was successfully removed from ECMO. She was discharged one month after her admission. The new technology available allows for ECMO to be considered as an earlier option for the treatment and management of these patients as a bridge to recovery.

Emergency management of decompensated peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare life-threatening cardiomyopathy of unknown cause that occurs in the peripartum period in previously healthy women.[1] the symptomatic patients should receive standard therapy for heart failure, managed by a multidisciplinary team. The diagnosis of PPCM rests on the echocardiographic identification of new left ventricular systolic dysfunction during a limited period surrounding parturition. Diagnostic criteria include an ejection fraction of less than 45%, fractional shortening of less than 30%, or both, and end-diastolic dimension of greater than 2.7 cm/m(2) body surface-area. This entity presents a diagnostic challenge because many women in the last month of a normal pregnancy experience dyspnea, fatigue, and pedal edema, symptoms identical to early congestive heart failure. There are no specific criteria for differentiating subtle symptoms of heart failure from normal late pregnancy. Therefore, it is important that a high index of suspicion be maintained to identify the rare case of PPCM as general examination showing symptoms of heart failure with pulmonary edema. PPCM remains a diagnosis of exclusion. No additional specific criteria have been identified to allow distinction between a peripartum patient with new onset heart failure and left ventricular systolic dysfunction as PPCM and another form of dilated cardiomyopathy. Therefore, all other causes of dilated cardiomyopathy with heart failure must be systematically excluded before accepting the designation of PPCM. Recent observations from Haiti[2] suggest that a latent form of PPCM without clinical symptoms might exist. The investigators identified four clinically normal postpartum women with asymptomatic systolic dysfunction on echocardiography, who subsequently either developed clinically detectable dilated cardiomyopathy or improved and completely recovered heart function.

Where is the "W"oman in MCH?

Scientific evidence indicates that improving a woman's health before pregnancy will improve pregnancy outcomes. However, for many years, our efforts have focused primarily on prenatal care and on caring for infants after birth. The concept of preconception care has been identified repeatedly as a priority for improving maternal and infant health. Preconception care is not something new that is being added to the already overburdened healthcare provider, but it is a part of routine primary care for women of reproductive age. Many opportunities exist for preconception intervention, and much of preconception care involves merely the provider reframing his or her thinking, counseling, and decisions in light of the reproductive plans and sexual and contraceptive practices of the patient. With existing scientific evidence that improving the health of "W"omen will improve the health of mothers and children, we must focus on improving the health of "W"omen before pregnancy and put the "W" in Maternal and Child Health.

A serious complication in the puerperium: peripartum cardiomyopathy

Two women, aged 27, presented with different symptoms shortly after giving birth to their first child. Peripartum cardiomyopathy (PPCM) was diagnosed. PPCM is a rare form of cardiac failure occurring late in pregnancy or in the postpartum period. Many women experience dyspnoea, fatigue, and pedal oedema in the last month of pregnancy or postpartum, symptoms which are identical to early congestive heart failure. Therefore, the diagnosis of PPCM requires vigilance. A high mortality rate and overall poor clinical outcome has been reported in a high percentage of these patients. Subsequent pregnancies remain controversial. (Neth Heart J 2008;16:415-8.).

Peripartum cardiomyopathy: prognostic factors for long-term maternal outcome

OBJECTIVE

The objective of the study was to assess the prognostic value of ejection fraction (EF) at index and subsequent pregnancy on long-term outcome in patients with peripartum cardiomyopathy (PPCM).

STUDY DESIGN

Seventy PPCM patients met inclusion criteria. Patients had echocardiography evaluations at the index pregnancy, at interval follow-up (F/U) or at the beginning of a subsequent pregnancy and the last F/U study available. Outcome data were echocardiographic parameters and the subsequent need for cardiac transplant.

RESULTS

Patients were categorized on the basis of their initial EF into EF of 25% or less and EF greater than 25% and stratified on the basis of their pregnancy into the following groups: group 1 (n = 33), no subsequent pregnancy; group 2 (n = 16), subsequent pregnancy with early termination; and group 3 (n = 21), successful subsequent pregnancy. F/U from index pregnancy to final F/U was 3.4+/-1.9 (range, 1-6 years). Groups 1 and 2 had persistent left ventricular dysfunction at all echocardiographic evaluations. In group 3, despite a mean EF greater than 40% at a subsequent pregnancy, 29% had worsening cardiac symptoms. Among 28 patients with EF of 25% or less, 16 (57%) had end-stage cardiac disease. One had a transplant and 15 were on a transplant list. All 16 had a baseline EF 25% or less at index pregnancy: 4 had improved (EF greater than 40%) at interval F/U and 3 at last F/U available.

CONCLUSION

Women with a history of PPCM had a higher rate of progression of symptoms of heart failure in a subsequent pregnancy. A baseline left ventricular EF 25% or less at index pregnancy is associated with a higher rate of cardiac transplant.

Peripartum cardiomyopathy: review of the literature

Peripartum cardiomyopathy (PPCM) is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Clinical presentation of PPCM is similar to that of systolic heart failure from any cause, and it can sometimes be complicated by a high incidence of thromboembolism. Prior to the availability of echocardiography, diagnosis was based only on clinical findings. Recently, inclusion of echocardiography has made diagnosis of PPCM easier and more accurate. Its etiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. Prompt recognition with institution of intensive treatment by a multidisciplinary team is a prerequisite for improved outcome. Conventional treatment consists of diuretics, beta blockers, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Cardiac transplantation may be necessary in patients not responding to conventional and newer therapeutic strategies. The role of the anesthesiologist is important in perioperative and intensive care management. Prognosis is highly related to reversal of ventricular dysfunction. Compared to historically higher mortality rates, recent reports describe better outcome, probably because of advances in medical care. Based on current information, future pregnancy is usually not recommended in patients who fail to recover heart function. This article aims to provide a comprehensive updated review of PPCM covering etiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis, while stressing areas that require further research.

Peripartum cardiomyopathy: a comprehensive review

Peripartum cardiomyopathy (PPCM) is a rare disorder in which left ventricular dysfunction and symptoms of heart failure occur in the peripartum period in previously healthy women. Incidence of PPCM ranges from 1 in 1300 to 1 in 15,000 pregnancies. The etiology of PPCM is unknown, but viral, autoimmune, and idiopathic causes may contribute. The diagnostic criteria are onset of heart failure in the last month of pregnancy or in first 5 months postpartum, absence of determinable cause for cardiac failure, and absence of a demonstrable heart disease before the last month of pregnancy. Risk factors for PPCM include advanced maternal age, multiparity, African race, twinning, gestational hypertension, and long-term tocolysis. The clinical presentation of patients with PPCM is similar to that of patients with dilated cardiomyopathy. Early diagnosis and initiation of treatment are essential to optimize pregnancy outcome. Treatment is similar to medical therapy for other forms of dilated cardiomyopathy. About half the patients of PPCM recover without complications. The prognosis is poor in patients with persistent cardiomyopathy. Persistence of disease after 6 months indicates irreversible cardiomyopathy and portends worse survival.

Cardiomyopathy in pregnancy and caesarean section: Four case reports

We present the clinical details of four women with cardiomyopathy who required caesarean section. Two women had peripartum cardiomyopathy and two had hypertrophic obstructive cardiomyopathy, one of whom has had two caesarean sections. Those with peripartum cardiomyopathy were more compromised than those with hypertrophic obstructive cardiomyopathy. Co-operation between obstetric and cardiac anaesthetists ensured optimum experience was available. An incremental combined spinal-epidural technique with invasive monitoring was used for three women and one received general anaesthesia. The risks and benefits of different anaesthetic techniques are discussed.

The significance of autoimmunity in myocarditis

A growing body of evidence supports the view that some forms of human myocarditis and dilated cardiomyopathy result from a pathogenic autoimmune response. The evidence is based first on the presence of heart-specific antibodies in many patients with these diseases, including antibodies with demonstrated functional effects. These antibodies may be present before the onset of dilated cardiomyopathy and may be predictive of the course of disease in terms of deterioration of cardiac function. Depletion of the heart-specific antibodies by extracorporeal immunoadsorption may result in amelioration of disease in some patients, often continuing for long periods of time. Clinical investigations show that a subpopulation of patients with dilated cardiomyopathy benefit from immunosuppressive treatment. In one report, this subpopulation was identified as autoantibody-positive and virus-negative. Finally, animal experiments have shown that autoimmune myocarditis can be induced by viral infection and that this autoimmune response can be duplicated by immunization with a well-characterized antigen, cardiac myosin. Based on this evidence, we propose that some forms of dilated cardiomyopathy and myocarditis result from pathogenic autoimmune responses that represent the final common pathogenetic pathway of various infectious and even non-infectious injuries.

Acute pulmonary edema in pregnancy

Pulmonary edema is a secondary disease process characterized by an excess accumulation of fluid in the pulmonary interstitial and alveolar spaces, preventing adequate diffusion of both oxygen and carbon dioxide. The excess fluid accumulation interferes with maternal oxygenation and, if not identified and corrected, can lead to maternal and fetal hypoxemia. The purpose of this article is to review principles of oxygen transport and the pathophysiology, diagnosis, management, and nursing implications of acute pulmonary edema in pregnancy.

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.

Prognostic Value of Echocardiography in Peripartum Cardiomyopathy

OBJECTIVE

To estimate whether echocardiography findings at the time of diagnosis of peripartum cardiomyopathy are predictive of persistent cardiac dysfunction.

METHODS

Chart review of patients with peripartum cardiomyopathy between 1988 and 2001 was performed. Data from echocardiography, including fractional shortening and left ventricular end diastolic dimension, were recorded both at the time of diagnosis and at follow-up. Left ventricular dysfunction was defined by echocardiography as fractional shortening less than 30% and left ventricular end diastolic dimension of 4.8 cm or more.

RESULTS

Of 32 patients meeting our definition for peripartum cardiomyopathy and for whom follow-up data were available, 13 (41%) had recovery of ventricular function, while 19 (59%) continued to have persistent left ventricular dysfunction. Those who did not recover cardiac function had a higher left ventricular end diastolic dimension and a lower fractional shortening at diagnosis than those who recovered. A fractional shortening value less than 20% and a left ventricular end diastolic dimension 6 cm or greater at the time of diagnosis was associated with a more than 3-fold higher risk for persistent left ventricular dysfunction.

CONCLUSION

Along with being an important diagnostic tool in peripartum cardiomyopathy, echocardiography may provide significant prognostic information with regards to recovery of cardiac function.

Breast feeding, bottle feeding, and maternal autonomic responses to stress

OBJECTIVE

The aim of this study was to examine the effects of breast feeding on autonomic nervous system (ANS) response to stressors.

METHODS

Sympathetic and parasympathetic activities were examined before, during, and after standard laboratory stressors in women who were either exclusively breast feeding (n=14) or nonexclusively breast feeding (n=14), and in non-postpartum controls (n=15).

RESULTS

Mothers who breast fed exclusively showed greater levels of parasympathetic cardiac modulation and slower heart rate (HR) throughout the session and less HR increase and preejection period (PEP) shortening to mental arithmetic (MA) than did nonexclusive breast feeders and controls. Nonexclusive breast-feeders showed greater electrodermal reactivity to, and greater differences in skin conductance response (SCR) frequency between baseline and recovery from cold pressor (CP) than did either exclusive breast-feeders or controls. Sympathetic activity was negatively related to the number of breast feedings and positively related to bottle feedings.

CONCLUSION

Breast feeding shifts maternal ANS balance toward relatively greater parasympathetic and lesser sympathetic activity; the opposite occurs with bottle feeding. The frequency of feeding also is a critical factor in determining breast feeding effects on maternal ANS function.

Pregnancy and the cardiovascular system

The cardiovascular system undergoes important adaptations during pregnancy to accommodate for fetal requirements. This causes a hemodynamic burden on patients with underlying heart disease, and is associated with significant morbidity and mortality. Moreover, certain cardiovascular diseases may be due to pregnancy. Although unusual, these diseases can pose a threat to the pregnant woman and her fetus. This review will discuss cardiovascular adaptations to pregnancy as well as the risk of pregnancy in patients with underlying heart disease. It will also provide a brief overview of cardiovascular disorders associated with pregnancy.

Successful Use of Levosimendan in a Patient with Peripartum Cardiomyopathy

This case represents the first reported use of levosimendan, a calcium-sensitizing drug with additional vasodilation properties, for treatment of a woman with peripartum cardiomyopathy. Levosimendan induced a steady decline of increased pulmonary capillary wedge pressure, followed by a definitive increase in cardiac stroke volume. The patient recovered from this serious episode of heart failure, and she ultimately regained left ventricular function.

IMPLICATIONS

Acute heart failure is a life-threatening event that only rarely occurs during childbirth. We report a case of a woman who experienced cardiovascular collapse during vaginal delivery. We determined that she met current diagnostic criteria for peripartum cardiomyopathy, and we successfully treated her with levosimendan, a calcium-sensitizing drug with additional vasodilation properties.

A case of peripartum cardiomyopathy with a transient increase of plasma interleukin-6 concentration occurred following mirror syndrome

Peripartum cardiomyopathy (PPCM) is an unusual heart failure of unknown etiology that occurs during pregnancy or postpartum. Mirror syndrome is a characteristic of maternal edema subsequent to fetal and/or placental edema. We report a case of PPCM with a transient increase of interleukin-6 concentration occurring in the postpartum period of mirror syndrome.

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.

Peripartum cardiomyopathy: a forgotten diagnosis?

Peripartum cardiomyopathy (PPCM) is a rare form of left ventricular failure with potentially fatal consequences, occurring during the last month of pregnancy or within the first 5 months after delivery. Diagnosis is by excluding all other causes of left ventricular failure and demonstrating characteristic echocardiographic findings. Management is similar to that of left ventricular failure of other causes.

Cardiac disease in pregnancy

Congenital heart disease in pregnancy is increasingly common because of the advances in surgery and medical therapy which have taken place over the last 30 years, which means that more affected women are surviving into the reproductive age. Antenatal counselling needs to be tailored to the specific lesion, with pulmonary hypertension and cyanotic disease presenting a risk of maternal mortality of up to 50%. The use of anticoagulants in women with artificial valves presents a particular challenge, heparin being safer for the baby and warfarin for the mother. Peripartum cardiomyopathy and Marfan's syndrome may be less dangerous than once thought. The risk of congenital heart disease in the fetus is increased, from twice to 20-fold, depending on the nature of the mother's lesion. Care throughout pregnancy and in the puerperium should be multidisciplinary and include cardiologists, obstetricians and midwives with experience of such cases, preferably in a tertiary centre.

Two cases of postpartum cardiomyopathy initially misdiagnosed for pulmonary embolism

PURPOSE

To underline the crucial role of urgent echocardiography in the differential diagnosis of acute respiratory and/or circulatory failure in the postpartum period.

CLINICAL FEATURES

A 24-yr-old woman was admitted to the intensive care unit (ICU) with a preliminary diagnosis of pulmonary embolism (PE) one week after Cesarean section. Neither computerized tomography nor Doppler sonography showed any signs of deep venous thrombosis or PE. In the ICU she required intubation and ventilatory support for acute respiratory and circulatory failure. Bedside echocardiography revealed features of left ventricular failure. A diagnosis of postpartum cardiomyopathy (PPCM) was made, appropriate treatment instituted and the patient soon improved. A 29-yr-old, previously healthy primipara presented at the Maternity Clinic on the fourth postpartum day complaining of increasing dyspnea and fatigue. Within eight hours she required intubation, ventilatory support and subsequent defibrillation due to cardiac arrest. She was transferred to the ICU with a preliminary diagnosis of PE. She developed pulmonary edema followed by cardiac arrest with successful resuscitation. Bedside echocardiography revealed a left ventricular ejection fraction below 30% with an increased systolic diameter of the left ventricle, restrictive diastolic abnormalities and no signs of pulmonary hypertension. Peripartum cardiomyopathy was diagnosed and supportive treatment for heart failure was instituted.

CONCLUSION

It is possible to misdiagnose postpartum cardiomyopathy for PE. An error in diagnosis is life-threatening for the patient. Echocardiography is a valuable tool in the differential diagnosis. As a noninvasive procedure, it should be performed at the bedside as soon as possible to institute proper treatment and to avoid potentially fatal errors.

Combined spinal-epidural anesthesia for Cesarean section in a patient with peripartum dilated cardiomyopathy

PURPOSE

To report a case of peripartum dilated cardiomyopathy associated with morbid obesity and possible difficult airway presenting for elective Cesarean section, which was successfully managed with combined spinal-epidural anesthesia.

CLINICAL FEATURES

A morbidly obese parturient with a potentially difficult airway, suffering from idiopathic peripartum cardiomyopathy (ejection fraction 20%), was scheduled for an elective Cesarean section. A combined spinal epidural anesthesia was performed and 6 mg of bupivacaine were injected into the subarachnoid space. This was supplemented after 60 min with 25 mg of bupivacaine injected epidurally. The patient's hemodynamic status was monitored with direct intra-arterial blood pressure and central venous pressure measurements. The patient's perioperative course was uneventful.

CONCLUSION

In patients suffering from peripartum cardiomyopathy, undergoing Cesarean section, combined spinal-epidural anesthesia may be an acceptable anesthetic alternative.