Monday, 3 January 2011

Peripartum cardiomyopathy

Definition:


(1)development of heart failure in the last month of pregnancy within 5 months after delivery
(2)absence of a known cause
(3) without any heart disease prior to the last month of pregnancy
(4) documented systolic dysfunction


Risk factors
Advanced maternal age
Multiparity
PIH
Multiple pregnancy
Afro-Caribbean race


Symptoms

fatigue
Dyspnoea/paroxysmal nocturnal dysponea
palpitations
pulmonary oedema/peripheral oedema
features of peripheral/cerebral embolism



Signs

elevated JVP
Cardiomegaly
third heart sound

Mitral/Tricuspid regurgitation
crepitations
hepatomegaly
Ascites




Systemic embolism occurs in 25-40% of patients with cardiomyopathy.
Investigation-Diagnostic criteria

Left ventricular ejection fraction <45%>

Left ventricular end diastolic pressure (LVEDP) >2.7cm/m2


Fractional shortening <30%>Chest Xray-Cardiomegaly/Pleural effusion/patchy lower lung infiltrates vascular redistribution

ECG- may helpful in excluding other causes

Endomyocardial biopsy done some times.

Invasive haemodynamic monitoring is considered if there is not a good response to medical treatment.

Newyork heart association classification can be used
I- asymptomatic
II-mild symptoms or symptoms only with extreme exertion
III-Symptoms on minimal exertion
IV- symptoms at rest Management


conventional treatment for heart failure is generally used.

Diuretics
vasodilators(hydralazine &/ nitrates)
cardio selective beta blockers(bisoprolol) or beta blockers with vasodilating action (carvedilol)

digoxin
ionotropes
ACEI-after delivery

salt restriction is recommended

Thromboprophylaxis

Elective delivery if antenatal.If cervix is favourable vaginal delivery is preferable,otherwise caesarean section may be chosen.Skilled epidural anaesthesia is useful for both routes of delivery.

Immunosuppressive therapy if myocarditis confirmed by endometrial biopsy.

Temporary support can be given by intraaortic balloon pumps & left ventricular assist devices.

Cardiac transplantation is indicated if intractable heart failure persists optimal medical therapy


Postpartum
Breast feeding isn't contraindicated.


Prognosis



Outcome of peripartum cardiomyopathy is variable.
Some patients recover rapidly but others may deteriorate to state requiring cardiac transplantation.
50% of patients make full recovery.
Echocardiography is repeated every six months to assess the recovery.
Prognosis depend on recovery of left ventricular size & function within 6 months.



Persistence of cardiac dysfunction beyond 6 months an indication of irreversible damage and such should be advised against pregnancy

Stress echocardiogram using dobutamine can be used to assess the contractile reserve.This would help in pre pregnancy counseling.Recurrence rate has been upto 50%

4.In future pregnancy women should have regular echocardiography


Sources

1.Nelson-Piercy C. Handbook of obstetric medicine. Taylor & Francis; 2002.



2Swiet MD. Medical disorders in obstetric practice. Wiley-Blackwell; 2002.


3.E-medicine

4.Peripartum Cardiomyopathy [Internet]. 2001 May 24 [cited 2009 Dec 12];Available from: http://content.nejm.org/cgi/content/extract/344/21/1629


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