What are the other Names for this Condition? (Also known as/Synonyms)

• Postpartum Cardiomyopathy
• PPCM (Peripartum Cardiomyopathy)
• Pregnancy-Associated Cardiomyopathy (PACM)

What is Peripartum Cardiomyopathy? (Definition/Background Information)

• Peripartum Cardiomyopathy (PPCM) is a condition in which the heart gets weakened during the final month of pregnancy or within 5 months after delivery. It is a type of dilated cardiomyopathy, in which the heart is unable to pump blood efficiently, which in turn affects other organs of the body
• Although the exact cause of Peripartum Cardiomyopathy is not known, it has been suggested that viral infections, an immune response to fetal or cardiac cells, and low selenium levels in the mother, may cause PPCM. Pregnancy at an advanced age, high blood pressure during pregnancy, and obesity are potential risk factors for developing the same
• Peripartum Cardiomyopathy may manifest as rapid heartbeats, fatigue, chest pain, and dizziness, among other symptoms. These symptoms are considered along-with physical examinations, lab tests, and imaging studies, to arrive at a diagnosis
• The condition may cause sudden heart failure and pulmonary embolus in the mother. When pumping of blood in the mother is affected, the fetus may be distressed as well
• Medications and lifestyle changes may be necessary to treat stable Peripartum Cardiomyopathy. If the condition gets progressively worse, then sometimes, a heart transplantation may be recommended
• The outcome is favorable, if the heart returns to normal function after delivery of the baby. However, if the heart continues to be enlarged, subsequent pregnancies may weaken it leading to a heart failure
• Leading a healthy lifestyle with balanced meals and regular physical activity may aid in the prevention of Peripartum Cardiomyopathy

Who gets Peripartum Cardiomyopathy? (Age and Sex Distribution)

• Peripartum Cardiomyopathy occurs in pregnant women, or women who have recently given birth to a child. Typically, the symptoms manifest in the last month of pregnancy, or in the first 5 months following delivery of the child
• The condition is more frequently observed in the developing nations, when compared to advanced/developed countries. For example, the incidence rate in some African countries is approximately between 1:100 and 1:1000, whereas in the USA, it is about 1:2200

The highest incidence rate has been reported in the Hausa and Fulani ethnic groups of northern Nigeria, at 1:100.

What are the Risk Factors for Peripartum Cardiomyopathy? (Predisposing Factors)

The following are some known risk factors for the development of Peripartum Cardiomyopathy:

• Pregnancy at an advanced age (over the age of 30 years)
• High blood pressure during pregnancy (pre-eclampsia), or after delivery (postpartum hypertension)
• Multiple pregnancies (i.e., twins, triplets, or more)
• Obesity
• Being malnourished, poverty
• Smoking, drinking alcohol
• Anemia during pregnancy
• History of heart conditions, such as myocarditis or inflammation of the heart
• Use of medications, such as tocolytics, for a prolonged period; these medications are given to suppress premature labor
• Belonging to African-American heritage

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider

What are the Causes of Peripartum Cardiomyopathy? (Etiology)

The exact cause of Peripartum Cardiomyopathy is not known. Multiple factors may contribute to the development of PPCM, which may include the following:

• Inflammation of the heart, also known as myocarditis
• Some viral infections including those caused by Coxsackie virus, Epstein- Barr virus (EBV), human herpes virus (HHV), and cytomegalovirus (CMV), and others
• Autoimmune response leading to production of antibodies against normal cardiac tissue proteins
• Inflammatory response to the presence of fetal cells in the mother's body (microchimerism) 
• Deficiency in nutrients, such as selenium
• Abnormal prolactin metabolism: Prolactin is a hormone and its levels increase during pregnancy. The hormone plays important roles in pregnancy and preparation of a woman’s body for nursing

What are the Signs and Symptoms of Peripartum Cardiomyopathy?

The type and severity of signs and symptoms of Peripartum Cardiomyopathy may vary between individuals, and may include the following:

• Fatigue
• Racing heart or skipped heartbeats
• Swelling of the legs
• Shortness of breath during physical activity or resting
• Chest pain
• Dizziness
• Coughing out blood (hemoptysis)
• Abdominal pain
• Increased night-time urination
• Excessive weight gain during the last month of pregnancy

How is Peripartum Cardiomyopathy Diagnosed?

The heart condition is diagnosed as Peripartum Cardiomyopathy when the following 3 criteria are present:

• Heart failure in the last month of pregnancy, or within 5 months of delivery
• Decreased pumping of blood from the heart, with an ejection fraction of less than 45%
  • Ejection fraction or EF is the percentage of blood pumped by the left ventricle with each contraction, when compared to the total amount of blood in the chamber. A value of 55-70% is considered normal
• No other identifiable cause for heart failure is evident

The diagnosis of PPCM is made based on the following tests and exams:

• A thorough physical examination and assessment of symptoms
• An evaluation of medical history, with emphasis on previous heart conditions
• Chest X-ray
• Computed tomography (CT) scan of the chest
• Coronary angiography: It is a test in which a dye and special X-rays are used to show the inside of the blood vessels supplying the heart
• Echocardiogram: It is a test in which sound waves are used to create a moving picture of the heart
• Nuclear heart scan: A test that is used to provide valuable information about the health of the heart
• Biopsy of the heart to check, if PPCM is associated with inflammation of the heart 

Note: The above tests may show an increase in the size of the heart, decreased movement, or functioning of the heart, decreased output by the heart, stasis of blood in the blood vessels of the lungs, and failure of the heart.

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Peripartum Cardiomyopathy?

The potential complications of Peripartum Cardiomyopathy may occur in the mother and/or the fetus:

In the mother:

• Cardiac arrhythmia: Irregular heartbeats, which may lead to sudden arrest of the heart
• Failure of the heart (congestive heart failure)
• Blood clot in the lungs (pulmonary emboli)

In the developing fetus:

• Fetal distress may occur due to decreased blood supply to the placenta, as a result of decreased pumping by the mother’s heart

How is Peripartum Cardiomyopathy Treated?

The treatment options for Peripartum Cardiomyopathy are aimed at providing relief from the presenting symptoms, stabilizing the function of the heart, and preventing fluid accumulation in the lungs. The treatment measures may include the following: 

Use of medications:

• Digitalis, to improve the heart's pumping ability
• Angiotensin converting enzyme (ACE) inhibitors, to improve efficiency of pumping
• Diuretics (water pills), to remove excess fluid in the body
• Low-dose beta blockers, to slowdown the heart rate so that the organ may recover

Bringing about certain lifestyle changes such as:

• Eating a nutritious and balanced diet
• Engaging in regular physical activities
• Restricting salt in the diet
• Smoking cessation
• Abstaining from alcohol
• Weighing oneself daily to gauge weight gain, since this can be indicative of excess fluid in the body (especially women with a high risk for PPCM)
• ACE inhibitors and blockers may be mixed with (transferred to) breast milk. Therefore, nursing the baby should be avoided while on the treatment regimen. These drugs can affect the newborn child

How can Peripartum Cardiomyopathy be Prevented?

Suitably addressing the following risk factors may aid in the prevention of Peripartum Cardiomyopathy:

• Avoiding cigarettes and alcohol
• Avoiding pregnancy (to the extent possible), if there is a history of heart failure in previous pregnancy
• Exercising to increase one’s cardiovascular fitness

What is the Prognosis of Peripartum Cardiomyopathy? (Outcomes/Resolutions)

• The prognosis of Peripartum Cardiomyopathy is determined by the severity of the condition. Those with stable and mild symptoms generally recover faster and better than those with progressive and severe PPCM
• The outcome is good, when the heart returns to normal size after childbirth. This occurs in about 50% of those affected; in whom, a complete recovery may be noted
• However, if the heart remains enlarged after birth of the baby, future pregnancies may lead to heart failures (30% probability), resulting in poorer outcomes

It is estimated that approximately 4% of women with PPCM may require a heart transplantation; 9% of those who undergo the procedure, are known to succumb to complications that arise from the transplant procedure.

Additional and Relevant Useful Information for Peripartum Cardiomyopathy:

Many online support groups are available as to guide the mothers with Peripartum Cardiomyopathy, such as:

http://www.circleofmoms.com/moms-with-peripartum-cardiomyopathy