Peripartum Cardiomyopathy TOG 2021

Question 1

Leading cause of direct material death?

Answer 1

Thrombosis

Question 2

Rates of PP cardiomyopathy, most common in which ethnicities?

Answer 2

1/1000-4000
Highest Nigeria (1/100)/Haiti (1/300)

Question 3

RF PPCM

Answer 3

Multiple pregnancy
HTN in pregnancy
Multiparty
Advanced Mat Age
Afro-carribean

Question 4

Mortality rate of PPCM?

Answer 4

10%

Question 5

Symptoms of heart failure

Answer 5

Dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
Pedal edema
Unexplained cough, particularly when lying down or which produces frothy pink sputum
Dizziness
Palpitation
Fatigue
Chest pain
Abdominal discomfort

Question 6

Evaluation for ?PP cardiomyopathy

Answer 6

History: known congenital or acquired heart disease? Family history of ischaemic/non-ischaemic heart failure?

Physical examination: tachypnoea, tachycardia, peripheral oedema, jugular venous distension.

Electrocardiogram: no specific pattern in PPCM but may rule out ischaemic or thromboembolic cause.

Blood tests: haemoglobin, C reactive protein, white cell count, natriuretic peptides, troponin T, blood gas analysis if unstable.

Echocardiography: crucial in diagnosing PPCM. Left ventricular ejection fraction (LVEF) <45%, ventricles may or may not be dilated.

Other investigations: chest X-ray, cardiac magnetic resonance imaging and rarely endomyocardial biopsy.

Question 7

What BNP/NT-proBNP/ECHO who make you concerned for PPCM?

Answer 7

BNP >100
NT-proBNP >300
EF <45%

Involve cardiology, consider PPCM and other causes

Question 8

What features should severe acute heart failure?

Answer 8

SBP <90
HR >130
RR >25
SPo2 <90
Lactate >2
ScvO2 <60%
Altered mental state
Cold skin
Oliguria

Question 9

If severe acute heart failure/cardiogenic shock antenatally

Answer 9

MDT discussion of timing delivery

If stable → Heart therapy
Hydralazine
Nitrate
Beta blocker
+/- diuretic

Question 10

If severe acute heart failure/cardiogenic shock postnatally

Answer 10

ACE/ARB
Beta blocker
MR antagonist
Diuretic
+/- bromocriptine

Question 11

If LVEF <35% AN or PN

Answer 11

Wearable cardioverter defibrillator if LVEF <35%

Anticoagualtion

Question 12

What is the recommended BB in pregnancy

Answer 12

Metoprolol

Question 13

If PPCM and persistent LV dysfunction, chance of deterioration in future pregnancy and mortality rate

Answer 13

50% chance deterioration (if LV fully recovered 20%)
20% mortality rate

Question 14

What % of women diagnosed with PPCM achieve recovery in LVEF >50%?

Answer 14

50-80% mostly within 6 months
Reduced if afro-carribean

Question 15

Which women should be counselled against future pregnancy?

Answer 15

LV not fully recovered
LVEF at Dx <25%