This one is dedicated to all women and their families who have been affected by Peripartum Cardiomyopathy (PPCM). Seldom detected, systolic heart failure can come as a surprise especially in young women. Developing heart failure during pregnancy, in the post-partum period or any other time throughout a subsequent pregnancy is not something any woman wants to worry about specially around the birth of their child.
The 2010 Heart Failure Association of the European Society of Cardiology Working Group defines PPCM to “an idiopathic cardiomyopathy presenting with Heart Failure (HF) secondary to Left Ventricular (LV) systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found”1, hence a diagnosis of exclusion.
The annual incidence of PPCM continues to increase. Women present with wide range of HF symptoms. Although some have complete recovery with guideline directed medical treatment, others have persistent myocardial dysfunction, advance heart failure and death which subsequently leads to devastating consequences for an entire family. Delays in diagnosis usually occur because the symptoms and signs of PPCM can mimic the normal findings of pregnancy. Early recognition and treatment of PPCM could lead to improvements in maternal and fetal mortality and morbidity. Easier said than done.
By the time a patient with PPCM sees a cardiovascular specialist, they often have worsening symptoms of heart failure with moderate to severe depressed left ventricular systolic function which means it was later recognized by either a primary care physician and/or an obstetrician-gynecologist prior to referral.
Awareness is key in early detection of PPCM. If you see something, say something. Think PPCM in all pregnant women. Since we mentioned that survival and recovery are both improved by early diagnosis, there is a validated self-test that can help with discerning heart failure from pregnancy related symptoms from Fett et al2. (Table 1.)
- Self-Test for Early Diagnosis of Peripartum Cardiomyopathy
|Symptoms||0 points||1 point||2 points|
|Orthopnea||None||Need to elevate head||Need to elevated 45 degrees or more|
|Dyspnea||None||Climb 8 or more steps||Walking on level|
|Unexplained cough||None||At night||Day and night|
|Excessive weight gain during last month of pregnancy||None||2-4 pounds per week||Over 4 pounds per week|
|Lower extremity edema||None||Below the knee||Above the knee|
|Palpitations||None||When Laying down at night||Day and night or any position|
The present of 4 or more points should prompt additional investigation.
Fett’s self-test can be an essential tool for the PCP and OB-GYN to aid in early detection of PPCM. Think about PPCM and use the self-test on all patients at risk to help guide further next steps in the diagnosis and management. In support of awareness of heart disease in women, think PPCM in which case the battle is half way won.
- Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010;12: 767–78.
- Fett, JD .Validation of a self-test for early diagnosis of heart failure in peripartum cardiomyopathy. Crit. Pathw. Cardiol. 10(1), 44–45 (2011).
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Michel Ibrahim is a physician cardiologist in training living the dream at the Boston University and Boston Medical Center. His clinical interests include cardiomyopathies, advanced heart failure, cardiogenic shock and hemodynamics. He has a specialist interest in global cardiovascular health. He is currently working on starting a non-profit organization to provide research, educational opportunities and tailored health care specific the island of Haiti. ON Twitter, follow @DrMichelIbrahim