Peripartum Cardiomyopathy (PPCM) What is PPCM? • A form of acute systolic heart failure that develops late in pregnancy or within 5 months postpartum. (Can occur later than 5 mos too) • Characterized by left ventricular ejection fraction <45%, without preexisting heart disease. Epidemiology: • Occurs in ~1 in 2000 births globally. • Higher incidence in: - Haiti (1 in 300) - Nigeria (1 in 100) • In the U.S., Black women are 4x more likely to develop PPCM than White women. Risk Factors: • Hypertensive disorders of pregnancy (e.g., preeclampsia) • Multiple gestations • Advanced maternal age • Anemia ✗ NOT a risk factor: Cesarean delivery Clinical Presentation: • Mimics normal pregnancy symptoms resulting in delayed diagnosis: - Dyspnea, orthopnea, edema • Can escalate to: ⚠️ Cardiogenic shock ⚠️ Arrhythmias ⚠️ Thromboembolic events • Key Point: High clinical suspicion is needed to avoid diagnostic delays Pathogenesis: Peripartum cardiomyopathy (PPCM) is caused by a combination of hormonal changes and heart vulnerability in late pregnancy or early postpartum: 🧬 Hormonal Triggers • Prolactin (cleaved form): damages blood vessels, harms heart cells • sFlt-1 & Activin A (from placenta): block blood vessel growth and damage heart function • Progesterone: impairs heart metabolism • ↓ Relaxin: reduces vascular protection 🧬 Underlying Susceptibility • Genetic variants (e.g., TTN): weaken heart muscle resilience • Other possible factors: inflammation, autoimmunity, nutrient deficiencies (e.g., selenium) Differential diagnosis: • Preexisting structural heart disease • Preeclampsia-induced pulmonary edema in the absence of systolic dysfunction • Pulmonary/amniotic embolism • Spontaneous coronary artery dissection • Exposure to toxins, including alcohol and chemotherapeutic agents • Valvular heart disease, including rheumatic disease • Myocarditis, including giant-cell myocarditis • Takotsubo cardiomyopathy • Tachycardia-induced cardiomyopathy • Pulmonary edema resulting from prolonged tocolysis • Sepsis, thyrotoxicosis, and other high-output causes of heart failure • Aortic dissection • Other causes of myocardial infarction, including MINOCA Diagnosis: • Echocardiography: LVEF <45% • Left ventricular dilatation is common but not always seen • Rule out other causes of heart failure • Consider biomarkers (e.g., BNP) and imaging • Nonspecific: sinus tachycardia on the electrocardiogram and pulmonary venous congestion on a CXR Outcomes & Prognosis: • 50% of patients experience recovery of cardiac function • However: - Up to 20% mortality - Higher in Black women and in resource-limited settings - Some patients require LVAD or heart transplantation Key Takeaways: • PPCM is underdiagnosed due to symptom overlap with pregnancy. • Early recognition and management can significantly improve outcomes. • Health disparities impact incidence, recovery, and mortality. • The neurohormonal changes of late gestation and parturition probably trigger peripartum cardiomyopathy in genetically or otherwise susceptible women #PPCM #Peripartum #Cardiomyopathy #Cardiology #OBGyn #Diagnosis
