Amr Peripartum

PERIPARTUM CARDIOMYOPATHY

Dr Amr Sobhy

M.D in anaesthesia and I.C.U

Lecturer in faculty of medicine ain shames university

ObjectivesDefinitionEpidemiologyDiagnosisManagementUpdatePrognosis

Definition

An idiopathic cardiomyopathy presenting with heart failure secondary to LV systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. It is a diagnosis of exclusion. The LV may not be dilated but the ejection fraction is nearly always reduced below 45%

Heart Failure Association of the ESC Working Group on PPCM (Sliwa et al., 2010)

Epidemiology

IncidenceThe incidence in the west ranges

from 1 in 4000 deliveries60% present within the first 2

months postpartumUp to 7% may present in the last

trimester of pregnancy. Geographic variations exist with a

higher incidence reported in areas of Africa .

Epidemiology

EtiologyStill unknown. Nutritional deficienciesSmall vessel coronary artery

abnormalityHormonal effectsToxemiaMaternal immunologic response

to fetal antigen or myocarditis

Epidemiology

Predisposing factorsMaternal age greater than 30 yr MultiparousTwinning Racial origin (black) Hypertension and eclamptic

patients Nutritional deficiencies No family history

DiagnosisCriteria1.Development of Cardiac failure in the last month of

pregnancy or within 5 month after delivery 2. Absence of an identifiable cause for the cardiac

failure. 3.Absence of recognizable heart disease prior to the

last month of pregnancy. 4.Left ventricular systolic dysfunction demonstrated

by classic Echo Cardio Graphic criteria such as depressed shortening fraction or ejection fraction.

The National Heart, Lung and Blood Institute and the Office of rare diseases (1997)

DiagnosisCriteria1.Development of Cardiac failure in the last month

of pregnancy or within 5 month after delivery

2. Absence of an identifiable cause for the cardiac failure.

3.Absence of recognizable heart disease prior to the last month of pregnancy.

4.Left ventricular systolic dysfunction demonstrated by classic Echo Cardio Graphic criteria such as depressed shortening fraction or ejection fraction.

The National Heart, Lung and Blood Institute and the Office of rare diseases (1997)

Diagnosis

Clinical PresentationSymptoms:

Paroxysmal Nocturnal Dyspnea

Dyspnea on Exertion

CoughOrthopneaChest PainAbdominal

DiscomfortPalpitation

Signs:CardiomegalyGallop RhythmEdemaHolosystolic

murmur

• Thromboembolic Manifestation

DiagnosisClinical PresentationOften unrecognized, as symptoms of

normal pregnancy commonly mimic those of mild heart failure.

In the absence of any cardiac symptoms, one of the early indications about this condition is Fetal growth retardation during evaluation of the fetus with a fetal monitor and ultrasound

DiagnosisInvestigation

1.Chest X rays Cardiomegaly with

pulmonary oedema Pulmonary venous

congestion.

2. The E.C.G Non specific ST and T

wave changes Atrial or ventricular

arrhythmias and conduction defects

DiagnosisInvestigation

3.ECHO Enlargement of all four

chambers with marked reduction in left ventricular systolic function

Small to moderate pericardial effusion

Mitral, tricuspid and pulmonary regurgitation

Ventricular wall motion, ejection fraction and cardiac output are decreased .

Pulmonary wedge pressure is increased.

ManagementConsultationsCardiologist

High-risk obstetrician

Anesthesiologist - Neuraxial anesthesia is preferred to avoid myocardial depression from inhaled anesthetics; for this reason, as the mother nears delivery, low-molecular-weight heparin should be used with caution.

ManagementVigorous treatment of AHF

Non-pharmacologicalSalt restriction (4gm/d)Water restriction (2 L/D)

PharmacologicalPre-load reduction (diuretics, nitrates)After-load reduction (hydralazine,

nitrates, amlodipine)ACE-I contraindicated during pregnancy

Ionotropes (digoxin, dopamine, dobutamine)

Beta-blockersAnticoagulant

Update in Management

Immunosuppressive agents May be initiated in patients with

PPCM and biopsy-proven myocarditis, but efficacy is unclear

Empiric immunosuppression, in the absence of evidence of myocarditis, is not currently recommended

Cardiac MRI could guide the immunosuppressive therapy

Update in Managementpentoxifylline

Update in Management Levosimendan

Update in Management

Bromocriptine

Update in Management

Since the disease may be reversible, the temporary use of Intra Aortic Balloon Pump or LV assist device may help to stabilize the patient’s condition pending improvement.

Update in ManagementCardiac Resynchronization Therapy

and Implantable Cardioverter/Defibrillators

LV ejection fraction < 35% persists after 6 months following presentation.

Patients with recurrent symptomatic ventricular arrhythmias

If NYHA III and IV heart failure symptoms and a QRS duration > 120 ms

Update in Management

Cardiac Transplantation

PrognosisPrognosis seems dependent on

recovery of left ventricular function. 30% of patients return to baseline

ventricular function within 6 months.The usual causes of death in patients

with (PPCM) are progressive heart failure, arrhythmia, or thromboembolism (30%).

PrognosisThere is an initial high risk period with

mortality of 25-50% in the first 3 months postpartum.

Patients with persistent cardiomegaly at 6 months have a reported mortality of 85% at 5 years.

Subsequent pregnancies in women with PPCM are often associated with relapses and high risk for maternal morbidity and mortality.

Should be discouraged in women with PPCM who have persistent cardiac dysfunction.

PrognosisSeveral factors for deterioration:

Age >30High ParityLater onset of six month Following pregnancy

Worse Echo findings on initial exam

Elkayam et al. N Engl J Med 2001; 344:1567

REMEMBER PPCM mimics changes occurring in

normal pregnancy Fetal growth retardation may point

towards this condition Treat like any other cardiac failure

along with anti coagulant therapy Epidural anaesthesia is preferable and

continue monitoring in an ICU Advice against subsequent

pregnancies.

Any questions