Peripartum cardiomyopathy: Treatment and prognosis

Authors
Wendy Tsang, MD
Amy C Bales, MD
Roberto M Lang, MD
Section Editor
Candice Silversides, MD, MS, FRCPC
Deputy Editor
Susan B Yeon, MD, JD, FACC
Disclosures: Wendy Tsang, MD Nothing to disclose. Amy C Bales, MD Nothing to disclose. Roberto M Lang,
MDGrant/Research/Clinical Trial Support: Philips Medical Imaging [imaging (echo machines)]. Speaker's Bureau:
Phillips [imaging (echo machines)]. Consultant/Advisory Boards: Phillips [imaging (echo machines)]. Candice
Silversides, MD, MS, FRCPC Nothing to disclose.Susan B Yeon, MD, JD, FACC Employee of UpToDate, Inc.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed
by vetting through a multi-level review process, and through requirements for references to be provided to support the
content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of
evidence.
Conflict of interest policy

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Feb 2015. | This topic last updated: Mar 04, 2015.
INTRODUCTION Peripartum cardiomyopathy (PPCM, also called pregnancy-associated
cardiomyopathy) is a rare cause of heart failure (HF) that affects women late in pregnancy or in the
early puerperium [1]. Although initially described in 1849 [2], it was not recognized as a distinct
clinical entity until the 1930s [3]. Earlier terms for this condition include toxic postpartum HF,
Meadows syndrome, Zaria syndrome, and postpartum myocardiosis.
Treatment of PPCM is similar to that employed for other types of HF with left ventricular systolic
dysfunction. However, modifications to standard therapy are often necessary to ensure the safety of
the mother and the unborn or breastfeeding child. (See "Management of heart failure during
pregnancy", section on 'Management goals'.)
Etiology, clinical manifestations, and diagnosis of PPCM, critical illness during pregnancy and the
peripartum period, HF during pregnancy, and issues related to pregnancy in women with acquired
or congenital heart disease are discussed separately. (See "Peripartum cardiomyopathy: Etiology,
clinical manifestations, and diagnosis" and "Critical illness during pregnancy and the peripartum
period" and "Management of heart failure during pregnancy" and "Acquired heart disease and
pregnancy" and "Pregnancy in women with congenital heart disease: General principles".)
MANAGEMENT Treatment of peripartum cardiomyopathy (PPCM) is largely similar to treatment
for other types of heart failure (HF). Additional therapeutic issues include arrhythmia management.
A pilot study suggested thatbromocriptine may be helpful but further study is needed [4].
Heart failure treatment
Components of therapy In women with PPCM and HF, the goals of medical therapy are similar
to those in patients with acute and chronic systolic HF due to other causes. These include:
Supplemental oxygen and assisted ventilation as needed
Optimizing hemodynamics

Relief of symptoms
When possible, chronic therapies that improve long-term outcomes.
Due to the unique issues related to pregnancy and the peripartum period, however, each
therapeutic decision has additional implications. The treatment of HF in pregnant and breastfeeding
patients is discussed in detail separately. Women with HF during pregnancy should be treated
similarly to other patients with HF, except for avoiding contraindicated medications such as
angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, and aldosterone
antagonists. (See "Management of heart failure during pregnancy", section on 'Treatment
regimens'.)
For women with peripartum cardiomyopathy who have delivered and are not breastfeeding, acute
and chronic HF are managed using standard therapy. (See "Treatment of acute decompensated
heart failure: Components of therapy" and"Overview of the therapy of heart failure due to systolic
dysfunction".)
Arrhythmia management Atrial fibrillation occurs occasionally in patients with PPCM [5].
Sustained ventricular tachycardia has rarely been reported with PPCM. Management of arrhythmias
during pregnancy is discussed separately. (See "Supraventricular arrhythmias during
pregnancy" and "Ventricular arrhythmias during pregnancy".)
Device therapy Decisions regarding use of implantable cardioverter defibrillator (ICD) and
cardiac resynchronization therapy in patients with PPCM should include consideration of the natural
history of these diseases, including the potential of recovery of ventricular function [1].
Specific indications for use of ICD therapy have not been established for PPCM [1], since scant
evidence on use of these devices is available in this patient population [6]. Since up to 20 to 60
percent of women with PPCM have complete recovery of left ventricular ejection fraction (LVEF) to
normal by six months to five years (see 'Recovery of left ventricular function' below), ICD placement
should generally be deferred at least three months and possibly even six months following
presentation, with the patient receiving optimum medical therapy to determine whether criteria for
placement are present. Whether a wearable defibrillator would prevent sudden cardiac death in
those being monitored for LVEF improvement is untested [7]. Furthermore, a wearable defibrillator
is not without its risks and concerns. (See"Primary prevention of sudden cardiac death in heart
failure and cardiomyopathy" and "Secondary prevention of sudden cardiac death in heart failure and
cardiomyopathy" and "Wearable cardioverter-defibrillator", section on 'Newly diagnosed
cardiomyopathy with LVEF 35 percent'.)
Information on the use of cardiac resynchronization therapy in PPCM is limited, but a limited
observational case series of eight patients suggests that resynchronization in medically optimized
patients resulted in improved systolic function and cardiac remodeling [8]. Cardiac
resynchronization therapy should generally be deferred until at least three months and possibly
even six months following presentation, with the patient receiving optimum medical therapy to
determine whether criteria for placement are present. (See "Cardiac resynchronization therapy in
heart failure: Indications", section on 'Indications'.)
Antithrombotic therapy Patients with PPCM are at high risk for thrombus formation and
thromboembolism due to both the hypercoagulable state of pregnancy and stasis of blood due to
severe LV dysfunction [9,10]. However, data are inconclusive on the utility of antithrombotic therapy

(antiplatelet therapy or anticoagulation) to reduce thromboembolic events or mortality in patients

with systolic HF who are in sinus rhythm. (See "Antithrombotic therapy in patients with heart failure",
section on 'Role of antithrombotic therapy'.)
Our approach to antithrombotic therapy in patients with PPCM is the same as that for other patients
with left ventricular systolic dysfunction (with or without HF). For patients with left ventricular systolic
dysfunction (with or without HF) without left ventricular thrombus or other indication for
antithrombotic therapy, we do not recommend not administering antiplatelet or anticoagulant
therapy. (See "Antithrombotic therapy in patients with heart failure", section on 'Our approach'.)
Although data are limited, we suggest anticoagulation for patients with PPCM who have acute
intracardiac thrombus or evidence of systemic embolism. This recommendation is consistent with
recommendations for management of acute ventricular thrombus or thromboembolism in patients
with HF generally. (See "Antithrombotic therapy in patients with heart failure", section on 'Role of
antithrombotic therapy'.)
Standard guidelines for antithrombotic therapy for atrial fibrillation should be followed in patients
with PPCM and atrial fibrillation, including recommending anticoagulation for patients with PPCM
with HF and atrial fibrillation. (See "Atrial fibrillation: Anticoagulant therapy to prevent embolization".)
For pregnant women who require anticoagulation, anticoagulation decisions and choosing a specific
anticoagulation regimen are challenging due to specific risks during various stages of pregnancy,
including the potential teratogenic effects of warfarin in the first trimester, dosing complexities of the
various agents, and management during labor and delivery. These issues are discussed in detail
separately. (See "Use of anticoagulants during pregnancy and postpartum".)
Mechanical circulatory support and cardiac transplantation Mechanical circulatory support
and heart transplantation are potential treatment options when HF is refractory to conventional
therapy. Older studies found that transplantation was performed in up to one-third of women with
PPCM [11-13]. Contemporary reports demonstrate that transplantation rates vary from 4 to 23
percent of patients [14-18]. Thus, women with PPCM and significant LV systolic dysfunction should
be managed at a center with transplant capabilities. (See "Indications and contraindications for
cardiac transplantation".)
In patients with PPCM, higher baseline LVEF is associated with high likelihood of recovery of LVEF
with medical management as discussed below. (See 'Maternal outcome' below.) However, the
baseline LVEF does not adequately predict the probability of recovery in individual patients. Thus, a
severely depressed baseline LVEF alone should not be considered an indication for premature use
of aggressive therapies such as ventricular assist devices and cardiac transplantation.
Mechanical circulatory support with a ventricular assist device can be used as a bridge to
transplantation or recovery when other therapies are not adequate to sustain life as the patient
awaits the arrival of a new heart, particularly if the patient is dependent on inotropes despite expert
HF therapy. Outcomes were reported for 1258 women, which included 99 with PPCM, who had
received durable mechanical circulatory support [19]. Women with PPCM who received durable
mechanical circulatory support had better survival than women without PPCM, with two-year
survival of 83 percent. These difference were likely due to the fact that women with PPCM were
younger and had less comorbidity. However, rates of recovery of myocardial function were poor at 6
percent in the PPCM group and 2 percent in those without PPCM. Indications and use of

mechanical circulatory support are discussed separately. (See "Circulatory assist devices:
Cardiopulmonary assist device and short-term left ventricular assist devices" and "Intermediate- and
long-term mechanical circulatory support" and "Practical management of long-term mechanical
circulatory support devices".)
In addition to the potential maternal and fetal risks related to pregnancy after heart transplantation
for any reason (see"Pregnancy after cardiac transplantation"), women who have been transplanted
for PPCM are at increased risk for graft failure. The largest series of cardiac transplantation for
PPCM included 485 patients from the UNOS database and found worse long-term survival in
patients transplanted for PPCM compared to all others undergoing transplantation [18]. Younger
patient age, higher allosensitization, higher pre-transplant acuity, and increased rejection rates are
all thought to play a role in these poorer outcomes.
Bromocriptine This treatment strategy is based upon an experimental observation of prevention
of PPCM in mice via prolactin blockade with bromocriptine [20]. A small randomized pilot study and
several observational reports have suggested a beneficial response to bromocriptine therapy in
patients with PPCM [4,21-24]. However, available data are insufficient to recommend routine use of
bromocriptine treatment for PPCM. Of note, the drug stops the production of breast milk making
breastfeeding impossible.
In a randomized open-label study performed in South Africa, 20 women with newly diagnosed
PPCM were randomly assigned to receive either standard care plus bromocriptine (2.5 mg twice
daily for two weeks followed by 2.5 mg daily for six weeks) or standard care alone [4]. The 10
women receiving bromocriptine demonstrated significantly greater improvement in LVEF as
compared to the 10 women receiving standard care only (27 to 58 percent versus 27 to 36 percent).
One patient in the bromocriptine group died as compared to four in the standard care group. Fewer
patients in the bromocriptine group reached the composite end point of death, New York Heart
Association functional class III or IV HF (table 1), or LVEF <35 percent at six months, as compared
to patients in the standard care group (one versus eight). The generalizability of these results is
unclear given the small sample size, the higher than expected mortality rate in the standard care
group, and differences in characteristics of PPCM in patients in Africa as compared to those
elsewhere [25].
This drug appears promising but there is insufficient evidence to establish the safety and efficacy
of bromocriptinetreatment for PPCM. Larger trials are needed.
Immunosuppressive agents Immunosuppressive therapy is not recommended for PPCM [1].
Although immunosuppressive therapy has been reported in patients with PPCM and biopsy-proven
myocarditis in an observational study [11], its efficacy is unclear. Empiric immunosuppression, in the
absence of evidence of a responsive form of myocarditis (eg, giant cell myocarditis), is not
recommended since most reported cases have nonspecific biopsy findings [26]. These drugs often
have significant side effects, and studies in other forms of myocarditis have not shown clear benefit
from immunosuppressive therapy [27]. (See "Natural history and therapy of myocarditis in adults",
section on 'Immunosuppressive therapy'.)
Intravenous immune globulin Intravenous immune globulin (IVIG) has been tried in patients
with myocarditis or recent-onset dilated cardiomyopathy with no clear evidence of clinical benefit. A
retrospective study of six women with PPCM treated with IVIG and 11 historical controls found a

greater increase in LVEF at six months in patients treated with IVIG compared to controls (26
versus 13 percent) [28]. However, the efficacy of this approach has not been confirmed in this
setting or other types of myocarditis. (See "Natural history and therapy of myocarditis in adults",
section on 'IVIG'.)
DELIVERY Limited data are available to guide the timing and mode of delivery in peripartum
cardiomyopathy (PPCM). Decisions regarding timing and mode of delivery should be based on
combined input from the cardiology, obstetrics, anesthesiology, and neonatology services [1]. In this
regard, multidisciplinary conferences are often useful.
In women with PPCM with advanced heart failure (HF), we suggest prompt delivery for maternal
cardiovascular indications. Urgent delivery may be required in women with advanced HF with
hemodynamic instability [1]. Planned cesarean delivery is preferred for women with advanced HF
requiring inotropic therapy or mechanical circulatory support [1,29].
For other women, the risks and benefits of early delivery should be considered and discussed with
the patient. The 2010 European Society of Cardiology working group statement advised that early
delivery is not required if the maternal and fetal conditions are stable [1]. However, patient-specific
issues, including gestational age, cervical status, fetal status, and the potential cardiovascular
impact of continuing pregnancy should be considered in timing delivery. As for women with other
types of cardiac conditions, cesarean delivery in patients with stable cardiovascular status is
generally reserved for obstetrical indications (eg, failure of progression of labor, placenta previa,
fetal intolerance of labor). (See"Acquired heart disease and pregnancy".)
BREASTFEEDING Some experts, including the 2010 European Society of Cardiology working
group, suggest that breastfeeding be avoided because of the potential effects of prolactin
subfragments [30]. (See "Peripartum cardiomyopathy: Etiology, clinical manifestations, and
diagnosis", section on 'Role of prolactin'.) However, one study designed to examine predictors of
ventricular recovery found that in 37 of 55 patients who chose to breastfeed, none had adverse
maternal effects and that rate of recovery of left ventricular function was significantly higher in
lactating women. Overall, given the benefits of breastfeeding and this report, some experts have
recommended that women who are clinically stable should not be discouraged from breastfeeding
as long as it is compatible with their heart failure medications [31].
If a decision is made to proceed with breastfeeding, we suggest avoiding angiotensin II receptor
blockers due to lack of safety data (see "Management of heart failure during pregnancy", section on
'Avoid angiotensin inhibition').
CONTRACEPTION Women with peripartum cardiomyopathy (PPCM) or history of PPCM should
receive counseling regarding risk of recurrence and family planning and contraception options.
Direct evidence is lacking on the safety of contraceptives in women with PPCM [32] and limited data
are available on the risk of recurrence, so our approach, which is consistent with the Centers for
Disease Control and Prevention guidelines, is based upon indirect evidence (table 2).
(See 'Prognosis' below.)
Since women with PPCM with persistent left ventricular (LV) dysfunction or LV ejection fraction
(LVEF) 25 percent at diagnosis are at high risk of recurrent PPCM, we suggest avoiding future
pregnancy in such patients [1]. We suggest that the patient or her partner undergo a sterilization

procedure or the patient use a highly effective non-estrogen method of contraception, such as
the etonogestrel implant, a copper intrauterine device (IUD), or levonorgestrel-releasing IUD.
Depot medroxyprogesterone acetate is not as highly effective, so it is considered a second line
alternative.
Though the risk of recurrence appears to be less in women with PPCM with recovered LV function
and LVEF >25 percent at diagnosis, such patients should receive counseling, including the option of
avoidance of subsequent pregnancy due to the risk of relapse of PPCM, heart failure, and death.
Estrogen-progestin contraceptives (eg, pills, patch, ring) may increase fluid retention, which may
worsen heart failure. In general, estrogen-progestin contraceptives should be avoided, particularly
early after diagnosis and in women with persistent LV dysfunction because of their potential to
increase the risk of thromboembolism [32,33].
PROGNOSIS The prognosis of peripartum cardiomyopathy (PPCM) must take into account
maternal, obstetric, and neonatal outcomes, and the effect of subsequent pregnancy.
Maternal outcome A number of studies have evaluated the outcome of women with PPCM
[6,14-16,34-38]. Whether women with PPCM have a different prognosis than pregnant women with
other forms of cardiomyopathy is not clear. (See "Acquired heart disease and pregnancy", section
on 'Cardiomyopathy'.)
Mortality and morbidity The mortality rate for PPCM has been reported as approximately 10
percent in two years [14], with rates ranging from 6 percent in five years (figure 1) [35] and 11
percent in three years [6] to as high as 28 percent in a report of 29 black patients [34]. Cardiac
transplantation rates of less than 1 to 2 percent per year have been reported [6,14,15].
Death due to PPCM is usually caused by progressive pump failure, sudden death, or
thromboembolic events. The following adverse prognostic factors have been identified in various
studies:
Worse New York Heart Association functional class (table 1) [39]
Left ventricular ejection fraction (LVEF) 25 percent [23]
Black race [29,34]
Indigent status [40]
Multiparity [29]
Age greater than 30 to 35 years [41,42]
PPCM is associated with significant extracardiac morbidity including brain injury. In a study of 182
women with PPCM, 46 had major adverse events (MAE) including death, cardiac transplantation,
mechanical circulatory support, cardiopulmonary arrest, fulminant pulmonary edema,
thromboembolic complications, and defibrillator or pacemaker implantation [43]. In half of the
patients with an MAE, the MAE preceded diagnosis of PPCM. One-third of patients who had an
MAE other than death or cardiac transplantation had residual brain damage as a result of
cerebrovascular accident or cardiopulmonary arrest.
Recovery of left ventricular function Partial or complete recovery of left ventricular function is
common among patients with PPCM and appears to be more frequent than with other types of
dilated cardiomyopathy [44]. Complete recovery of left ventricular function (defined as recovery to

an LVEF >50 percent) has been reported in 20 to 60 percent of patients in various series
[6,14,34,44-46]. Although nearly all recovery of LV function occurred within six months of diagnosis
in some series [14,34,47], delayed recovery of LV function has been observed in other studies
[6,40,48,49]. In one series of 100 patients, 42 women showed partial or complete improvement in
LVEF occurring over months to five years [6]. In this series, only 4 of 23 women who eventually had
complete recovery achieved this within six months.
Various studies have identified the following predictors of persistent LV dysfunction at follow-up:
LVEF 30 percent [14]
Fractional shortening less than 20 percent and an LV end-diastolic dimension 6 cm [50]
Elevated cardiac troponin T [51]
Black race [6,44]
Diagnosis during pregnancy [6]
While recovery of LV function in patients with PPCM is related to the degree of dysfunction at the
time of diagnosis, baseline LVEF has limited sensitivity for prediction of improvement in individual
patients [45]. Small preliminary studies of the value of dobutamine stress echocardiography to
predict recovery of LV function have yielded mixed results [52,53].
Obstetric and neonatal outcomes Data are more limited on obstetric and fetal outcomes. In the
above report of 123 patients, cesarean delivery was performed in 40 percent of patients, largely for
obstetric indications [14]. Preterm birth (<37 weeks) occurred in 25 percent, the mean birth weight
was 3.1 kg (range 1.4 to 5.0 kg), and 5.9 percent of infants were small for date. There were two
stillbirths, one neonatal death, and four newborns had congenital anomalies.
Subsequent pregnancy Women with PPCM or history of PPCM should receive counseling
regarding the risk of recurrence with subsequent pregnancies [1]. Termination of pregnancy may not
prevent relapse. Although limited data are available, we suggest that patients with PPCM with
persistent LV dysfunction or LVEF 25 percent at diagnosis should be advised to avoid a
subsequent pregnancy due to the risk of HF progression and death [1]. Other patients with PPCM
should also be advised of the risk of recurrence. (See 'Contraception' above.)
The available data on risk of recurrence of PPCM come from several small case series, which
suggest that the risk of complications is high, particularly among women who do not have full
recovery of LV function.
Recovered LV function Among women in whom LV function returns to normal, the risk of
subsequent pregnancy appears lower than for those with persistent LV dysfunction, but elevated
compared to the general population [54,55]. In a series of 28 women who recovered to an LVEF
50 percent after the initial episode, the following results in subsequent pregnancies were noted
[54]:
There were no deaths
There was a reduction in the mean LVEF (56 to 49 percent), and the LVEF fell by more than
20 percent in six women (21 percent).
Six patients developed HF symptoms

The persistent risk in such women may be related to subtle residual dysfunction that is not detected
on resting evaluations. Support for this hypothesis comes from a report of seven women with a
history of PPCM who regained normal resting LV size and performance [38]. Contractile reserve,
assessed by dobutamine challenge, was significantly impaired compared to matched controls.
In summary, some women who recover LV function after an initial episode of PPCM will have
significant decline in LV function during a subsequent pregnancy. Women with PPCM with
normalized LV function should be counseled about the potential risks of recurrence and carefully
monitored for signs of ventricular dysfunction if they choose to become pregnant again.
Persistent LV dysfunction The potential risks of subsequent pregnancy in women who have
persistent LV systolic dysfunction appear to be substantial, as illustrated by the following
observations:
In a series of women with PPCM who had subsequent pregnancies, 16 women had
persistent LV dysfunction [54]. Among these women, three died (19 percent). In addition, there
was a further reduction in the mean LVEF (36 to 32 percent), heart failure (HF) symptoms
developed in seven patients, premature delivery in six, and therapeutic abortion in four.
In a report of six women who had subsequent pregnancies after PPCM, two who had
persistent LV dysfunction died three months postpartum due to HF [56].
A more complex pattern was illustrated in a review of 15 women with PPCM, 14 of whom had
incomplete LV recovery [57]. Subsequent pregnancy resulted in worsening HF in eight women
(53 percent) and one death from worsening HF 10 months postpartum. Seven women did not
develop worsening HF during the second pregnancy; these women all had continued
improvement and normalization of LV function (LVEF 50 percent) within 30 months of the
subsequent pregnancy.
SUMMARY AND RECOMMENDATIONS
The management of heart failure (HF) due to peripartum cardiomyopathy (PPCM) is similar
to that of HF due to other causes that occur during pregnancy with special attention to
particular risks during pregnancy, including fetal risks. (See 'Heart failure treatment' above
and "Management of heart failure during pregnancy", section on 'Management goals'.)
Decisions regarding use of implantable cardioverter defibrillator and cardiac
resynchronization therapy in patients with PPCM should include consideration of the natural
history of the disease, including the potential of recovery of ventricular function. (See 'Device
therapy' above.)
Preliminary data have suggested a benefit from bromocriptine in patients with PPCM, though
further studies are needed to establish safety and efficacy. (See 'Bromocriptine' above.)
Decisions regarding the timing and mode of delivery in PPCM should be made based upon
combined input from cardiology, obstetrics, anesthesiology, and neonatology services. Prompt
delivery is suggested in women with PPCM with advanced HF. (See 'Delivery' above.)
The limited available data suggest that the risk of recurrence with subsequent pregnancy is
highest among women with persistent left ventricular (LV) systolic dysfunction, although
women with recovered LV systolic function are also at risk for recurrence. (See 'Subsequent
pregnancy' above.)

All women with PPCM should receive counseling on the potential risk of recurrence with
future pregnancies. We suggest that women with a history of PPCM who have persistent LV
dysfunction or LV ejection fraction 25 percent at diagnosis be advised to avoid pregnancy
due to the risk of HF progression and death. (Grade 2C). (See'Subsequent pregnancy' above
and 'Contraception' above.)
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