THE CHECK-UP: Fast Facts about Peripartum Cardiomyopathy
by Dr. Habibat Aziz Garuba, MD, FRCPC
What is peripartum cardiomyopathy?
The term “cardiomyopathy” refers to a group of diseases or conditions that cause dysfunction of the heart muscle and often (but not always) enlargement of the heart. Peripartum cardiomyopathy (PPCM) is a condition associated with pregnancy that causes weakening of the heart muscle pumping function and enlargement of the heart or “heart failure” during the last month of pregnancy or within a few months of delivery. It is diagnosed only after other causes of heart failure have been investigated and excluded.
What causes peripartum cardiomyopathy? Am I at risk?
The exact cause of PPCM is unclear. One possible mechanism is due to the abnormal breakdown of a hormone called prolactin which normally functions to increase production of breastmilk among other things. The broken-down fragments of prolactin damage heart muscle tissue, stop the formation of new blood vessels, and cause increased inflammation. The result is weakening of the heart muscle and ultimately “heart failure” – the decreased ability of the heart to pump sufficiently to meet the body’s needs.
Black women are at much higher risk (at least 3-4 times higher) of developing peripartum cardiomyopathy than other ethnic or racial groups and are at significantly higher risk of dying or having complications from it. The exact reasons for this are not known. From available literature, PPCM is estimated to occur in about 1 in 3000 to 1 in 4000 pregnancies in the United States, but the incidence is much higher in Black women (~1 in 1000) and also much higher in African and Caribbean countries e.g. South Africa (1 in 1000) and Haiti (1 in 300). Some literature suggests that the Hausa ethnic group in Northern Nigeria has the highest known incidence of PPCM in the world.
Other situations that can increase the risk of developing PPCM include:
- Having had peripartum cardiomyopathy with a previous pregnancy
- Multiple childbirths
- Pregnancy in a woman over the age of 30 years
- History of pre-eclampsia or eclampsia
- Hypertension in pregnancy
- Cocaine use
- Alcohol use
- Prolonged use of certain medications to suppress premature labour
What are the symptoms of peripartum cardiomyopathy?
Women may experience shortness of breath with physical activity or when lying down, increased swelling in the legs and feet, and increased urination at night. Sometimes, these symptoms may be mistaken for the usual symptoms of the third trimester of pregnancy. Occasionally, women may have a persistent cough, abdominal discomfort, or abdominal bloating. They may also experience palpitations (a sensation of a “rapid heartbeat”), dizziness, low blood pressure, or chest pain. In severe cases, clots may form in the heart and can dislodge to blood vessels in other parts of the body (e.g. in the brain causing a stroke). In extreme cases, PPCM can manifest as fluid accumulation in the lungs, life-threatening abnormally fast heart rhythms, and even a cardiac arrest or sudden death.
How is peripartum cardiomyopathy diagnosed and treated?
An echocardiogram (ultrasound of the heart) is used to measure the pumping function of the heart and helps diagnose PPCM once other causes of abnormal heart function have been evaluated and excluded.
Once diagnosed, standard medications used to treat heart failure are also used to treat peripartum cardiomyopathy such as ACE inhibitors and beta-blockers. These help the heart recover by allowing it pump more efficiently, limiting the abnormal enlargement of the heart muscle, and slowing down the heart beat so it has more time to recover. Diuretics are often used to treat fluid overload. Digoxin may be used to help with abnormal heart rhythms and may improve the pumping ability of the heart. Some of these medications may need to be avoided prior to delivery as they may not be safe for the baby.
Salt intake should be avoided to reduce accumulation of fluid. The total daily amount of fluid allowed may also be restricted for the same reasons. Alcohol and smoking should be avoided. In some experimental cases, a medication called bromocriptine which blocks the production of the hormone prolactin may be used, however it can also cause reduced production of breastmilk and may stop it altogether. In some cases, some women may be advised not to breastfeed as it increases the metabolic demands on the weakened heart.
What are the complications of peripartum cardiomyopathy?
The prognosis is variable. Untreated peripartum cardiomyopathy can lead to complete heart failure and death in some cases. The risk of death varies across the world from 0-9% in Caucasians in the USA up to 15% in African Americans as well as populations in South Africa and Haiti.
About 50% of women completely recover and have a normal heart size and function within a few months of delivery. The rest either have a stable but reduced heart muscle function or develop greater worsening of their heart muscle function. The risk of recurrence of PPCM is 30-50% with the next pregnancy. In particular, women who have persistent heart muscle dysfunction are at very high risk of further complications (including death) with subsequent pregnancies. Women who have had PPCM in the past and who have residual heart muscle dysfunction are strongly advised to avoid further pregnancies.
Women with severe heart failure that does not recover with treatment may ultimately need to have a heart transplant.
How can I reduce my risk?
Adhering to a healthy low fat diet, regular exercise, avoiding cigarette smoking and avoiding alcohol can help reduce the risk although these habits may not eliminate the risk. Women who have had PPCM in the past may need to consider contraception to prevent future pregnancies given the high risk of recurrence.
Where can I find more information?
American Heart Association:
Sliwa K et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010;12: 767 – 778.
Regitz-Zagrosek et al. European Society of Cardiology Guidelines on the management of cardiovascular diseases during pregnancy. Eur Heart J 2011;32: 3147 – 3197.
Dr. Habibat A. Garuba is currently a Resident Physician at the University of Ottawa Heart Institute completing her specialization in Adult Cardiology. She is a Fellow of the Royal College of Physicians of Canada, licensed in the specialty of in Internal Medicine. She also holds a Bachelor of Science degree in Pharmacy from the University of Toronto. Her areas of interest include clinical cardiology, echocardiography (cardiac ultrasound), heart failure, global health, and pharmaceutical policy.
THE CHECK-UP is a column aimed at increasing awareness and providing general information on selected health topics that are prevalent in people of African and Caribbean descent. The information presented is not exhaustive and does NOT represent personalized medical advice nor does it replace an individualized assessment and treatment by a physician or other medical professional. Please contact your doctor or seek medical attention if you have any concerns about your health or any matters referenced in this article.