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Lowest risk for relapse of heart failure ** in a post-PPCM pregnancy: 

  • LVEF ≥ 55 %.
  • Maintain LVEF after discontinuation of heart failure Rx (may be required to continue beta-blockade).
  • Adequate contractile reserve as estimated from exercise stress echo NOTE:   This does not guarantee relapse-free pregnancy, just gives an idea about reserve for stresses of pregnancy/delivery.
  • Normal LV size, shape and function ("reverse remodeling" to LVEF  55 % and LVEDD < 6 cm).
  • No evidence of diastolic dysfunction

**Always some risk for relapse of heart failure.   There can be no guarantees for relapse-free pregnancy; but under the best recovery conditions indicated above, a relapse, when recognized early, is very treatable.

Monitoring a post-PPCM pregnancy:

  • Echocardiogram each trimester and postpartum
  • Plasma BNP each trimester and postpartum (rising levels hours to days before clinical heart failure)
  • Physical exam for signs and symptoms each trimester and postpartum
  • Self-test for pregnancy-associated heart failure each trimester and postpartum

NOTE:  We are in initial phases of a post-PPCM pregnancy study that will help to identify who is at greatest risk for relapse of heart failure in a post-PPCM pregnancy and who has the least risk for relapse.   This study should be underway in 2016-2017.   Watch for further notice.

References: 

Fett JD, Christie LG, Murphy JG. Outcomes of subsequent pregnancy after peripartum cardiomyopathy: a case series from Haiti. Ann Int Med 2006 Jul 4; 145:30-4.

Fett JD, Fristoe KL, Welsh SN. Risk of heart failure relapse in subsequent pregnancy among peripartum cardiomyopathy mothers. Int J Gynecol Obstet 2010;109:34-6.

Fett JD.  Personal Commentary:  Monitoring subsequent pregnancy in recovered peripartum cardiomyopathy mothers.  Critical Pathways in Cardiology 2010;9:1-3.

Fett JD, Fristoe KL, Welsh SN.  Risk of heart failure relapse in subsequent pregnancy among peripartum cardiomyopathy mothers.  International Journal of Gynecology & Obstetrics 2010;109:34-6.

Self-test for recognition of heart failure during or just after pregnancy:*

 

  •       Orthopnea (difficulty breathing when lying flat): (a) None 0 points; (b) Need to elevate head 1 point; (c) Need to elevate 45 degrees or more 2 points.
  •       Dyspnea (shortness of breath on exertion): (a) None 􏰀0 points; (b) Climbing 8 or more steps 􏰀1 point; (c) Walking on level 2 points.
  •      Unexplained cough: (a) None  0 points; (b) At night 1 point; (c) Day and night 2 points.
  •       Swelling (pitting edema) lower extremities: (a) None 􏰀0 points; (b) Below knee 1 point; (c) Above and below knee 2 points.
  •       Excessive weight gain during last month of pregnancy: (a) Under 2 pounds per week􏰀0 points; (b) 2 to 4 pounds per week􏰀1 point;  (c) Over 4 pounds per week 2 points.
  •      Palpitations (sensation of irregular heart beats): (a) None  0 points; (b) When lying down at night 􏰀1 point; (c) Day and night, any position 2 points.

ACTION:  5 or more points = see cardiologist re:  plasma BNP   and echocardiogram.  Score of 5 or more has always been associated with decreased LVEF (so far).

*Fett JD.  Validation of a self-test for early diagnosis of heart failure in peripartum cardiomyopathy.  Crit Pathw Cardiol 2011;10 (Mar):44-45.


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