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A. Characteristics and Etiology navigator

  1. ~1:2000-4000 live births
  2. More common in Older, multiparous, black patients
  3. Toxemia and Twin Pregnancies have increased risk
  4. Chronic Hypertension
  5. ? Diffuse Myocarditis
  6. Usually within 3 months of delivery
  7. Thromboembolic stroke and brain hemorrhage incidence also increased peripartum [2]

B. Pathologynavigator

  1. Dilatation of all cardiac chambers
  2. Pale appearing myocardium
  3. Ventricular Thrombi
  4. Disintegration of sarcoplasm and heart muscle fibers
  5. Myocarditis
    1. 30-80% of patients with PPCM have evidence of myocarditis
    2. Endomyocardial Biopsy: Viral, Autoimmune (possible cocksackievirus), ? Toxin
  6. Molecular marker sof inflammation are found in most patients

C. Symptoms and Signs navigator

  1. Dyspnea, Orthopnea
  2. Cough, Hemoptysis
  3. Fatigue, Chest Pain
  4. Biventricular Failure (cardiomegaly)
  5. Tachycardia
  6. Hypertension (early on)
  7. Pulmonary Congestion with rales
  8. Echocardiography critical to evaluating left ventricular (LV) dysfunction
  9. May also present with symptoms related to thromboembolism

D. Managementnavigator

  1. Outcomes
    1. About 50% improve without therapy
    2. About 25% have recurrent CHF
    3. Overall better prognosis than other forms of dilated cardiomyopathy [3]
    4. Increased risk of LV dysfunction, heart failure, and death with subsequent pregnancies
    5. Women whose LV function does not return to normal after initial pregnancy are at highest risk for death or severe heart failure with next pregnancy [4]
  2. Concern for systemic embolization
  3. Bedrest, Sodium Restriction (1.5-2gm/day)
  4. Management of the CHF
    1. Furosemide
    2. Potassium and magnesium supplements to maintain serum levels
    3. ß-adrenergic blockers are used early - reduce heart rate, arrhythmias
    4. Hydralazine ± nitrates for afterload reduction during pregnancy
    5. ACE inhibitors preferred afterload reduction but are contraindicated during pregnancy
    6. Digoxin - slow load may be helpful but caution as complications are high
    7. Intravenous inotropic support as needed
    8. Heparin is given to reduce risk of thromboembolism
    9. Pulmonary artery catheterization during and post delivery may be helpful
  5. Management of Myocarditis
    1. Prednisone 40-60mg po qd
    2. Consider azathioprine as a glucocorticoid sparing agent
    3. The evidence for efficacy of these agents is sparse

References navigator

  1. Silwa K, Fett J, Elkayam U. 2006. Lancet. 368(9536):687 abstract
  2. Kittner SJ, Stern BJ, Feeser BR, et al. 1996. NEJM. 335(11):768 abstract
  3. Felker GM, Thompson RE, Hare JM, et al. 2000. NEJM. 342(15):1077 abstract
  4. Elkayam U, Tummala PP, Rao K, et al. 2001. NEJM. 344(21):1567 abstract