Peripartum Cardiomyopathy

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    This article covers definition, signs and symptoms, diagnosis and treatment of peripartum/ postpartum cardiomyopathy. It is a subject not often written or talked about, but in honor of National Heart month, i felt it was import to write

    Peripartum Cardiomyopathy

    Peripartum or postpartum cardiomyopathy (PPCM) is a rare cardiac condition that causes enlargement of the heart and weakening of the cardiac muscle. This decreases the ability of the heart to deliver oxygen and meet the demands of other body organs. PPCM occurs during the last month of pregnancy up to 5 months postpartum, but most commonly has its onset in the hours to first few days post delivery.

    The American Heart Association says that PPCM occurs in only 1,000-1,300 women in the United States per year. Most women, when diagnosed and treated early, can regain normal heart function but in severe cases PPCM can cause permanent damage to the heart muscle. The onset of peripartum cardiomyopathy is often unforeseen and is emotionally taxing for the woman and families that are affected.

    So what causes peripartum cardiomyopathy and what are the contributing factors that put some women at higher risk? While there is no known definitive cause of PPCM, there are a few conditions such as coronary artery spasm, abnormal immune response, genetics and prior cardiac disease that are being studied closer. During pregnancy, a woman’s body produces an additional 50% of blood volume to provide adequate circulation for the fetus and mother. This fact combined with any of the following contributing factors may increase the risk of developing PPCM.

    • Obesity
    • High Blood Pressure
    • Diabetes
    • History of heart disease or postviral heart disease
    • Smoking
    • Malnutrition
    • Alcoholism
    • African American descent
    • Maternal age over 30 years old
    • History of multiple pregnancies
    • History of PPCM with prior pregnancy
    • History of receiving medication to prevent premature delivery

    How is peripartum/postpartum cardiomyopathy diagnosed? Women display symptoms such as, shortness of breath, difficulty breathing while lying flat, rapid weight gain and edema in lower extremities. Additional clinical findings such as decreased blood pressure and crackles noted in the lungs would prompt the physician to do further testing. Echocardiogram, nuclear scan, CT scan and even a chest x-ray may show weakness, dilation of the left ventricle with decreased function, and/or thickening of the heart muscle. Several blood tests will also indicate heart failure. In order to be diagnosed with PPCM, women must meet these three criteria:

    • Timing of onset (last month of pregnancy up to 5 months postpartum)
    • Ejection fraction less than 45% (normal EF is 55-70%)
    • No other reason found for decreased EF and heart failure

    PPCM is further classified using the New York Heart Association System as follows:
    Class 1: Disease exists without symptoms
    Class 2: Mild signs and symptoms with extreme exertion
    Class 3: Signs and symptoms with minimal exertion
    Class 4: Signs and symptoms at rest

    Clinical management for patients with PPCM will differ based on classification and signs and symptoms. Patients will remain in the hospital until symptoms are controlled to minimize further complications such as cardiac arrhythmias, blood clots (particularly in lungs), congestive heart failure, and even death. Severe cases may require a cardiac balloon pump to assist heart function by helping offset cardiac workload. The most extreme cases may require a heart transplant due to the degree of irreversible damage to the heart muscle. Many cases will be managed with lifestyle changes and medication to stabilize heart function. There are many classes of medications that may be used to treat PPCM.

    • Beta blockers will decrease blood pressure and increase blood flow by blocking adrenaline.
    • Digitalis increases the strength of the heart's “pump” or squeeze.
    • Diuretics decrease blood pressure by removing sodium and water from the body.
    • Angiotensin- converting -enzyme inhibitors (ACE inhibitors) and/or Angiotensin Receptor Blockers (ARBs) help the heart work more effectively.
    • Anticoagulants prevent/ reduce coagulation of blood therefore prolonging blood clotting time.
    • A few lifestyle changes are also encouraged such as a maintaining a low sodium diet, and stopping all alcohol and nicotine use.

    To conclude, peripartum or postpartum cardiomyopathy is a rare cardiac disease that presents during the last month of pregnancy up to 5 months post pregnancy. It causes a weakening of the heart muscle with subsequent loss of cardiac function affecting multiple body systems. Most women recover normal heart function, while others have permanent severe heart failure requiring heart transplant. Nurses and other health care providers need to be familiar with and observant of the signs and symptoms of PPCM, especially in those patients with high risk factors. In addition to clinical care, providers need to be sensitive to treat the emotional and educational needs of the patient and family members, as this disease touches the whole family at a vulnerable time.

    For more information go to:
    Peripartum Cardiomyopathy (PPCM)
    PPCM Post Partum Cardiomyopathy Peripartum Cardiomyopathy Heart Failure in Pregnancy
    An obstetric emergency called peripartum cardiomyopathy!
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    My name is Sarah Matacale RN, BSN, CCS. I have practiced nursing for 20 years in a variety or care settings and have been enjoying time writing and educating patients, families and other healthcare providers.

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  3. by   Horseshoe
    Even though it is apparently "rare," I still had no idea it happened as often as it does. Thanks for the informative article.
  4. by   smatacale
    Me too! As a CCU RN in a major university medical center we treated several cases, so I was really surprised to see such low numbers.
  5. by   sunnyskies9
    Thanks for the informative article! Most insurance companies will cover cardiac rehab for patients with cardiomyopathy/CHF if their EF is less than 35%.
  6. by   smatacale
    Thank you for that additional info! Cardiac rehab is HUGE for these patients.....being postpartum and having gone through a cardiac event!
  7. by   FranEMTnurse
    Thank you so much for this informative article. I love to learn, and I learned something new today. I was in the ER a few years ago, and aftwr I had a chest x ray, the physician told me (looking surprised,) Mrs. LeMay, you have a very enlarged heart. I was also diagnosed with CHF at the time, and was intubated, because my pulse & respirations were declining. I also had septicemia at the time. I was left with permanent cardiomegaly, but my being on the correct maintenance drugs, I am living much longer than I would have if I was living in an area where there were no advanced healthcare facilities like there are where I live. I live very close to a medical school, and I am so thankful.
  8. by   The Nurse Motivator
    Well written and easy to follow. Thank you!

    I knew a woman that ended up with peripartum cardiomyopathy and in need of a heart transplant. She delivered at 24 weeks and remained on a ventricular assist device for about a month waiting for a heart transplant. Fortunately her gift arrived and she was able to go on with a fairly normal life. She and her daughter both went on to become avid spokes people for organ donation. What an even a more amazing gift to be able to watch her daughter grow opportunity that looked slim at one point.
  9. by   smatacale
    What an inspiring story! Thank you for sharing!
  10. by   RunnerNurse09
    Let me just say, I am ecstatic to see this topic featured. This happened to me several years ago and was diagnosed after my second baby. For all intents and purposes this never should have happened to me, and thank God it resolved on its own. I was young, no family history of heart disease, healthy, exercised, never smoked, no medical problems. The only thing I have ever read that may have been a contributing factor is that I had two pregnancies relatively close together. My EF originally reported as 45% with mild symptoms, but later after further testing was erroneously reported as 29% and I spent 3 weeks walking around thinking I was never going to see my kids grow up until I had a cardiac cath done. Couple years later I am at 68%. PLEASE admins, please post this in the Labor delivery forum. I have read horror stories about pregnant women with sob and swollen legs being blown off by their OBGYN's , only later to be diagnosed with this in a severe form. If you are pregnant and present with any symptoms that even have a hint of being cardiac, dont let your MD brush it off. Get it checked out. This was one of the scariest periods in my life.