Download - Amr Peripartum
PERIPARTUM CARDIOMYOPATHY
Dr Amr Sobhy
M.D in anaesthesia and I.C.U
Lecturer in faculty of medicine ain shames university
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 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
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.