When the diagnosis of peripartum cardiomyopathy (PPCM) can
be made very early in its course the systolic heart function will be better
preserved . When the echocardiographic left ventricular ejection
fraction (LVEF) is better, recovery outcomes will also be better .
Earlier diagnosis depends upon earlier recognition of symptoms that
may be very similar to normal term pregnancy symptoms. When all
of those involved in the care of new mothers, including the subjects
themselves, are aware of a possibility for the development of pregnancy-
associated heart failure in someone who has previously had perfectly
normal heart function, then earlier diagnosis can easily be confirmed
PPCM is still one of the leading causes of maternal mortality [3-5].
Unrecognized, it progresses at variable rates into severe heart failure
threatening the life of both mother and unborn child or neonate. While
not a common condition, it is also not rare. In the USA, incidence varies
from approximately 1 case per 1500 live births in those mothers with
African heritage to 1 case per 3000 in mothers without African heritage.
Delay in diagnosis may lead to maternal mortality, newborn fatality, or
survival of a mother with chronic cardiomyopathy and varying severity
of heart failure for the rest of her life. Nevertheless, PPCM is a form
of dilated cardiomyopathy with the greatest potential for full recovery,
particularly when diagnosed early and treated appropriately, following
evidence-based guidelines [2,6].
How can an earlier diagnosis of PPCM be made?
Greater awareness is already having an impact, leading to
improving outcomes. Increasing attention must be given to enhance
this awareness among all subjects with pregnancy as well as all their
medical caregivers, including birthing center personnel, obstetrical
nurses and aides, primary care physicians, emergency room physicians,
obstetricians and cardiologists.
A self-test for heart failure in pregnancy is available for
quantification of common symptoms . Scores of 5 and higher
continue to be validated as indicating the need for carrying out
additional testing, including serum B-type Natriuretic Peptide (BNP)
and/or echocardiography. It is important to work quickly in this
assessment because, once triggered, the PPCM process may move very
rapidly; in which case the LVEF falls to levels that risk the subject’s
susceptibility to ventricular tachyarrhythmias and sudden cardiac
arrest. Once recognized, early treatment reverses the cardiomyopathic
process and gives the greatest potential for avoiding those dangerous
levels of systolic dysfunction, providing the greatest potential for
subsequently returning to normal heart function.
What is the treatment of PPCM?
Evidence-based “Guidelines” for the initial treatment of heart failure
with reduced LVEF include diuretics, beta-blockers (BB) and ACE-
inhibitors or angiotensin receptor blockers (ACEI/ARB) in tolerable
dosages as “Class I (“should use”) recommendations . Usually,
ACEI are started first followed by BB when there is hemodynamic
stability; however, reverse order has been used and is also effective.
The combination of ACEI + BB seems to have a synergistic effect that
We do not yet know if the new dual angiotensin receptor blocker
(ARB) and neprilysin inhibitor (ARNI) will be more effective than an
ACEI; but it does show promise of benefit for some . We do know
that newer intervention trials are needed to help those who currently
are the most resistant to full recovery; namely, those who at diagnosis
have LVEF < 0.30 and left ventricular end-diastolic diameter (LVEDD)
≥ 6 cm .
Thus far, inhibition of the lactating hormone, prolactin, with
the use of bromocriptine has neutral or disappointing results; and
continuation of breastfeeding has not been shown to be detrimental to
recovery [2,10,11]. More work needs to be done on the prolactin theory
of causation to be sure that findings on the mouse model can indeed
translate to the human model, in which there may be more resistance to
cleavage of normal prolactin into a cardiotoxic metabolite (genetically
First priority is to initiate the recovery phase. The issue
of safety for subsequent pregnancies can be considered
It is helpful to indicate to the new mother that the safety of future
pregnancies depends upon achieving full recovery of heart function.
We now know that most women who experience full recovery are
indeed able to safely have a subsequent pregnancy [8,14,15]. We are
still learning about the risks for relapse of heart failure in subsequent
pregnancies. This type of relapse is still a possibility in some of those
Correspondence to: James D. Fett, MD, Peripartum Cardiomyopathy
Projects, 2331 Mt. Hood Ct. SE, Lacey, WA 98503, USA; Co-Director and
Steering Committee, Peripartum Cardiomyopathy Network (PCN), IPAC
=Investigations in Pregnancy-Associated Cardiomyopathy, (Principal
Investigator and Co-Director, Dennis McNamara, MD), Tel: 360-438-5270;
E-mail: [email protected]
Received: November 06, 2015; Accepted: December 07, 2015; Published:
December 10, 2015