Peripartum cardiomyopathy is a disorder of the heart muscle that can be experienced from one month pregnant, late pregnancy, before delivery, up to 5 months after delivery . Although not a common disease, peripartum cardiomyopathy can cause serious complications and increase the morbidity and mortality in pregnant women. The mortality rate due to peripartum cardiomyopathy varies between 5-50% in several countries.
The risk factors associated with peripartum cardiomyopathy in several studies are hypertension in pregnancy, preeclampsia, multiple pregnancies, maternal age over 30 years, and family history of cardiomyopathy. The cause of peripartum cardiomyopathy is not known with certainty, but there are several hypotheses that relate it to the inflammatory response in the heart muscle, oxidative stress and prolactin, and microchimerism .
Signs and Symptoms of Peripartum Cardiomyopathy
In peripartum cardiomyopathy there is a decrease in the function of the heart's contractions to pump blood throughout the body. Interruption of contractions causes blood pooling or congestion with symptoms such as:
- Shortness of breath on activity
- Shortness of breath when lying down
- Coughing or waking up at night due to shortness of breath
- Swelling in both lower limbs
- Weight gain due to fluid buildup
- The stomach is getting bigger, there is a feeling of fullness
These complaints are often ignored because during pregnancy there are often similar complaints as the gestational age increases.
Diagnosis of peripartum cardiomyopathy
The diagnosis of peripartum cardiomyopathy is based on:
- There are complaints of congestion that is felt one month before up to five months after giving birth
- The contractile function of the left heart is less than 45% on echocardiography.
Supporting investigation
Investigations carried out to establish the diagnosis and rule out other diagnoses in peripartum cardiomyopathy include:
- Echocardiography
Echocardiography is performed to assess heart function, contractility of the left and right sides of the heart, size of the heart chambers, presence or absence of heart muscle thickening, heart valve abnormalities, presence of thrombus, and other structural abnormalities.
- Electrocardiography (EKG)
Electrocardiographic examination is not specific in the diagnosis of peripartum cardiomyopathy. Normal electrocardiographic examination results do not rule out the diagnosis of peripartum cardiomyopathy. However, the EKG examination can assess whether there is an enlarged heart, heart rhythm abnormalities, or other electrocardiographic abnormalities.
- Laboratory examination
Levels of Brain Natriuretic Peptide (BNP) and N terminal pro-BNP will be greatly increased in peripartum cardiomyopathy, but in normal pregnancy it is not significantly increased, as well as in preeclampsia it is usually only slightly increased.
- Endomyocardial Biopsy
If there are suspicions such as giant cell myocarditis, an endomyocardial biopsy can be performed to rule out the differential diagnosis.
Management of peripartum cardiomyopathy
Management of peripartum cardiomyopathy is given immediately after the diagnosis is made by considering its safety for pregnant and lactating women. The treatment given is divided based on the patient's clinical condition, namely acute and chronic. In case of respiratory failure or severe shortness of breath, treatment in the intensive care unit is required. In acute conditions, supportive therapy is given to improve hemodynamic conditions, reduce symptoms and achieve good outcomes for the mother and her fetus. Supportive therapy is given in the form of diuretics, vasopressors and intropes. Other therapies given in the form of heart failure therapy include diuretics, beta blockers, hydralazine and nitrates. Some therapies such as angiotensin converting enzyme inhibitors and aldosterone antagonists are teratogenic, therefore they can only be given after the baby is born.
Prognosis and Pregnancy After Experiencing Peripartum Cardiomyopathy
Women who have had peripartum cardiomyopathy are at risk of developing cardiomyopathy in subsequent pregnancies. The risk in subsequent pregnancies mainly depends on the full recovery of cardiac muscle function after a previous cardiomyopathy event and the contractile function of the heart before pregnancy. Based on the 2018 European Society of Cardiology guidelines, it is recommended to prevent further pregnancies if the contractility function of the heart after peripartum cardiomyopathy is not more than 50%. Women with more than 50% recovery of myocardial contractility have a lower risk of complications in subsequent pregnancies, but still have a higher risk of recurrent heart failure. Consultation with doctors and counseling in planning pregnancy after peripartum cardiomyopathy is very necessary.
Article written by dr. Ina Nadia, Sp.JP, FIHA (Cardiologist and Blood Vessel Specialist at EMC Sentul Hospital).