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Peripartum Cardiomyopathy

Peripartum Cardiomyopathy. Matthew Voth M.D. WCGME Dept. of Ob/Gyn – PGY-1. Case Presentation. N.A. 22 y.o. G1 P0 @ 40 WGA presented to LDR with chief complaint: contractions 2/85/-1 on initial exam 3/90/-1 recheck 1 hour later Admitted to BCC for Expectant Management of Labor.

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Peripartum Cardiomyopathy

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  1. Peripartum Cardiomyopathy Matthew Voth M.D. WCGME Dept. of Ob/Gyn – PGY-1

  2. Case Presentation • N.A. 22 y.o. G1 P0 @ 40 WGA presented to LDR with chief complaint: contractions • 2/85/-1 on initial exam • 3/90/-1 recheck 1 hour later • Admitted to BCC for Expectant Management of Labor

  3. Antepartum • 109 lbs on initial exam. Gained 27 lbs during pregnancy • 28 week Hgb 10.1. Pt unable to tolerate Niferex during pregnancy • C/O back pain requiring prn Lortab • Otherwise unremarkable antepartum care

  4. Case Presentation cont.. • Initial Vital signs: BP 134/78, P-60 R-16 • Progressed along labor curve for several hours with occasional variable decel. • Good BTBV, overall reassuring • At 0500 called to evaluate prolonged deceleration, pt was rushed to OR for emergent C/S.

  5. No complications EBL 1000cc APGARS 8/9 Tight nuchal cord Pt. To recovery in stable condition Emergent C/S

  6. Postpartum Care • Hgb on admission 11.5 gm/dl • 6 hours post-op 7.4 gm/dl • 800cc LR bolus given • Typed and Crossed for 2 Units • Hbg rechecked 8 hours later, 6.8 gm/dl • 500cc bolus given

  7. Postpartum Day #2 • A.M. Hgb 7.4 gm/dl • Pt. Not tachycardic, BP’s stable 130’s/70’s • Urine output >100cc/hour • IV DC’d PPD #2

  8. Postpartum Care cont… • Pt. Remained asymptomatic. • Vital signs remained stable until PPD#3 • 4 consecutive BP’s >140/90 and HR >110 • Pt. Tol PO well. IV not restarted • C/O Headache • PIH labs ordered - WNL

  9. Postpartum Care cont…. • PPD #4, Hgb 7.4 • BP 138/85, pt. Asymptomatic • Discharged home

  10. ER Visit PPD#7 • 4 days after dismissal pt. Returned to ER with complaints of: • Shortness of breath-more pronounced when lying down • Chest heaviness when lying down • Lightheadedness x 2 days

  11. BP 143/100 Pulse 83, regular RR 19 O2 sat 100% on 1L 2+ edema LE’sL Lungs crackles heard at bases bilaterally PIH labs ordered 20 mg Lasix given in ER Admitted to 3-WH Cardiology consulted Dx: R/O cardiomyopathy Physical Exam

  12. Cardiology consult • EKG- normal • BMP – WNL • CBC – Hgb 8.1 gm/dl • TSH - WNL • Troponin I –WNL • BNP – 949 normal range (<100 pg/ml) • Echo – Dilated cardiomyopathy

  13. Cardiology Consult cont…. • PE: reported an S3 gallop • Lasix 40 mg IV x1 then 20mg PO daily • Lisinopril 5mg PO x1 then 10mg PO BID • KCl 40mg PO x1 then 10 mg PO BID • Ativan 0.5mg PO prn • Daily I’s and O’s

  14. 3-Women’s • Post admit day 1- pt reportedly much improved. Breathing easier. Ambulating. Voiding >90cc/hour. • Edema diminishing • Post admit day 2 – pt. Discharged home, asymptomatic. Vital signs stable. 3 kg weight loss.

  15. Review of Cardiac Changes in Pregnancy • Increase in blood volume • As early as 4th week • 10-15% at 6-12 weeks • Rises rapidly thru 32-34 weeks then a modest rise • Net result = 1100 – 1600 cc increase or 30-50% above baseline *Lund et al. Am J Obstet Gynecol 1967; 98:393

  16. Review cont…. • Increase in TBV due to: • Increased vascular capacitance • Systemic vasodilation ….as opposed to pure blood volume expansion Renin is increased and ANP decreased (would suspect alternate with pure BV expansion) Shier et al N Eng J Med 1988; 319:1127

  17. Review cont…. • Elevation of CO rises 30-50 % • Due to 3 important factors: • Preload is increased due to increase in TBV • Afterload is reduced due to decreased SVR • Maternal HR rises 15-20 bpm Robson, et al. Am J Physiol 1989; 256:H1060.

  18. *Chapman et al. Kidney Int 1998; 54:2056

  19. What is a Cardiomyopathy?? • Characterized by dilation and impaired contraction of one or both ventricles. • Affects systolic funtion • Pt. May or my not develop overt heart failure. *Richardson et al. Circulation 1996 93:841

  20. Overall responsible for 10,000 deaths and 46,000 hospitalizations each year Wide age range 20-60 *Dec et al. N Engl J Med 1994; 331:1564 Common Sx: Progressive dyspnea with exertion Impaired exercise capacity Orthopnea Paroxysmal nocturnal dyspnea Peripheral edema Cont…..

  21. *Felker et al. N Engl J Med 2000; 342:1077

  22. Peripartum Cardiomyopathy • 4% of all cardiomyopathies • 1:3000-4000 preg. • Dilated Cardiomyopathy

  23. Should we be concerned?? • Yes! • CDC Pregnancy Related Mortality Surveillance 1991-1999 • Leading Causes of Maternal Mortality: • Embolism – 20% • Hemorrhage – 17% • Hypertension – 16% • Peripartum Cardiomyopathy- 9%***

  24. Etiology • Multiple studies have attempted to elucidate a distinct etiology…..all have failed • Theories: • Myocarditis • Abnormal Immune Response • Genetics • High postpartum salt intake

  25. Myocarditis?? • Nairobi Study1986 • 11 African women with PPCM • Endocardial biopsies done on all eleven • 5 showed evidence of “healing myocarditis” • Presence of inflammatory cells • Necrosis • Fibrous remodeling • 9 patients finished study • 75% of myocarditis group developed persistent heart failure • 80% of patients without myocarditis improved *Sanderson et al. Br Heart J 1986: 56:285

  26. Myocarditis? Cont… • Another study: • 84 women with cardiomyopathies • 14 diagnosed as being PPCM • 29% of patients with PPCM were found to have myocarditis • Only 9% of idiopathic CM related to myocarditis *O’Connell et al. J AM Coll Cardiol 1986; 8:52

  27. Myocarditis? Cont…. • 3rd Study: • 18 patients with PPCM • 14 due to myocarditis • 10 of these received immunosuppressive Tx over 6-8 weeks, then tapered over 6-8 weeks • 9 of 10 improved on therapy • However, 4 of 4 not receiving therapy also improved *Midei et al. Circulation 1990; 81:922

  28. Myocarditis? Cont…. • 1994 Retrospective study • 34 patients diagnosed with PPCM • Researches found lower incidence of myocarditis than previously reported • 8.8 % due to myocarditis • Why the discrepancy?? * Rizeq et al. Am J Cardiol 1994; 74:474

  29. Abnormal Immune Response? • Maternal immunologic response to a fetal antigen? • Fetal cells may escape into the maternal circulation without being rejected. • May become lodged in cardiac tissue. • May trigger immune response *Nelson et al. J Am Med Womens Assoc 1998; 53:31

  30. Immune Response? Cont…. • Disproved 1990., Nigerian Study • 39 women with PPCM • No differences between subjects and controls in levels of: • Serum Immunoglobulins • Circulating Immune Complexes • Cardiac muscle antibodies *Cenac et al. Int J Cardiol 1990; 26:49

  31. Genetics • Several case reports published • 1963, Pierce et al. reported that 3 of 17 patients with PPCM had definitive FH of same condition • 1984 Voss et al. reported a patient who died from PPCM as did her mother and two of her sisters • 1993 Massad et al. reported 16 y.o girl with PPCM following molar preg. Sister later received cardiac transplant for PPCM. Cont….

  32. Genetics cont…. • Also, 1976 Strung documented male relatives of female patients with PPCM as also having cardiomyopathies. • Hard to retrospectively study…. • Can not determine every patient who develops PPCM was completely healthy before pregnancy. *Pearl Am Heart J 1995;129:421-2

  33. Age >30 years old Multiparity African Descent Maternal cocaine abuse Long term tocolytic therapy (>4weeks) Pregnancy with multiple fetuses History of Preeclampsia, eclampsia, or postpartum HTN Risk Factors

  34. Criteria for Diagnosis • 4 Criteria • Development of Heart failure in the last month of pregnancy, or within 5 months postpartum • Absence of a determinable cause for cardiac failure • Absence of heart disease before last month of pregnancy • Left Ventricle impairment demonstrated on Echo

  35. Symptoms: Paroxysmal Nocturnal Dyspnea Dyspnea on Exertion Cough Orthopnea Chest Pain Abdominal Discomfort Palpitation Signs: Cardiomegaly Gallop Rhythm Edema Holosystolic murmur Clinical Presentation

  36. Timing of Diagnosis • Dx. Requires being in the last month of pregnancy • If earlier, consider underlying heart disease (ischemic, valvular, or myopathic) • 2nd trimester burden

  37. Diagnosis • EKG • Two-dimensional echocardiogram • CXR • Lab: CBC, CMP, BNP, TSH, Ferritin • If persistent past initial therapy: • Cardiac catheterization • ?Myocardial biopsy

  38. EKG Changes • Sinus Tachycardia • Nonspecific ST changes • LV Hypertrophy

  39. Chest X-ray • Pulmonary Edema • Venous congestion • Enlarged Cardiac Silhouette • R/O PE

  40. Echocardiogram • Spherical LV • Mitral and Tricuspid regurgitation • Left Atrial enlargement • EF <55%

  41. Case Presentation • EKG WNL • CXR-mild edema • Echo: • EF 47% • Mild Mitral Regurg • Mild LV dilatation • Mild LV hypokinesis • Mild LA dilatation

  42. Treatment • Delivery • Similar to other forms of CHF • Diuretics • ß-blockers • Digoxin • Anticoagulants *Must consider pregnancy class/breast-feeding harm potential!

  43. Pregnancy Drug Class Review • Category A: Controlled studies in pregnant women fail to demonstrate a risk to the fetus in the first trimester with no evidence of risk in later trimesters. The possibility of harm appears remote • Category B: Presumed safety based on animal studies, with no controlled studies in pregnant women,   or animal studies have shown an adverse effect that was not confirmed in controlled studies in women in the first trimester and there is no evidence of a risk in later trimesters.

  44. Drug class cont….. • Category C: Studies in women and animals are not available  or  studies in animals have revealed adverse effects on the fetus and there are no controlled studies in women.  Drugs should be given only if the potential benefits justify the potential risk to the fetus • Category D: There is positive evidence of human fetal risk (unsafe), however in some cases such as a life-threatening illness the potential risk may be justified if there are no other alternatives

  45. Drug class cont…. • Category X: Highly unsafe: risk of use outweighs any potential benefit.  Drugs in this category are contraindicated in women who are or may become pregnant

  46. Digoxin Class C Symptomatic control Requires level monitoring Therapeutic levels 0.7-1.2 Drugs

  47. Lasix Class C Reserved for cardiac conditions Not recommended in PIH May decrease placental perfusion Thiazide Diuretics Reserved for cardiac conditions Not recommended in PIH Thrombocytopenia has been reported in breast feeding infants Diuretics

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