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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Development of cardiomyopathy with left ventricular dysfunction during the last trimester of pregnancy or in the early postpartum period

  • Absence of other etiologies of cardiomyopathy

  • No history of heart disease

GENERAL CONSIDERATIONS

  • The incidence in the United States ranges from 1 in 1000 to 4000 live births

  • The etiology is unclear, but the pathophysiology involves impaired angiogenic signaling and oxidative stress. Recent data suggest that peripartum cardiomyopathy may share a genetic origin with familial and sporadic dilated cardiomyopathy

  • More common in multiparous women. Preeclampsia and hypertension strongly predispose

  • Can affect women of any age, but > 50% of cases occur in women > 30 years of age

  • More common in black women

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Symptoms may be difficult to differentiate from those of normal pregnancy

  • Dyspnea

  • Dizziness

  • Fatigue

  • Orthopnea

  • Reduced exercise capacity

  • Cough

  • Palpitations

  • Hemoptysis

  • Chest pain

  • Abdominal pain

PHYSICAL EXAM FINDINGS

  • Tachypnea

  • Tachycardia

  • Elevated jugular venous pressure

  • Pulmonary rales

  • Diffuse, sustained apical impulse

  • Murmurs of tricuspid and mitral regurgitation

  • S3 gallop

  • Accentuated P2

  • Hepatomegaly

  • Abdominal ascites

  • Peripheral edema

DIFFERENTIAL DIAGNOSIS

  • Heart failure due to other causes

  • Pulmonary causes: pulmonary embolus, pneumonia

  • Acute pulmonary edema from prolonged tocolysis or preeclampsia

  • Other cardiac causes: myocardial infarction or takotsubo cardiomyopathy

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Levels of brain natriuretic peptide and troponin are typically elevated in peripartum cardiomyopathy and not usually elevated in normal pregnancy

  • Tests to exclude preeclampsia (CBC, liver enzymes, urinalysis for proteinuria)

  • Electrolytes, blood urea nitrogen, creatinine

  • Thyroid function tests

  • Serologic tests to exclude myocarditis (viral, HIV, rickettsial infection, syphilis, Chagas’ disease, diphtheria toxin) in suspected cases

  • Serologic tests to exclude collagen vascular disease when indicated

  • Urine toxicology to exclude cocaine and ethanol

  • Urine metanephrines to exclude pheochromocytoma in suspected cases

ELECTROCARDIOGRAPHY

  • Sinus tachycardia

  • Atrial fibrillation (rare)

  • Low-voltage QRS

  • Left ventricular hypertrophy

  • Nonspecific ST- and T-wave abnormalities

IMAGING STUDIES

  • Chest x-ray:

    • – Findings include cardiomegaly, pulmonary vascular congestion, pleural effusions

  • Echocardiography findings include:

    • – Abnormal enlargement of the left and sometimes the right ventricle

    • – Reduced systolic ventricular function of varying degrees in a global pattern

    • – Valvular regurgitation common

    • – Elevated continuous-wave Doppler tricuspid regurgitant velocity indicating elevated pulmonary artery systolic pressure

DIAGNOSTIC PROCEDURES

  • Stress echocardiography: test of choice during pregnancy for patients with suspected coronary artery disease

TREATMENT

CARDIOLOGY REFERRAL

  • Reduced left ventricular function

  • Congestive heart failure

  • Tachyarrhythmias

HOSPITALIZATION CRITERIA

  • Congestive heart failure

  • Syncope

  • Arrhythmia

  • Labor and delivery

MEDICATIONS

  • Angiotensin-converting ...

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