A recent aa2day summary described a case of a pregnant patient who suffered a cardiac arrest. The authors noted that the patient had a hyperdynamic left ventricle with concentric remodeling, signs of heart failure. It’s important that anesthesiologists caring for parturients understand the physiology and clinical presentation of heart disease, as well as the management of these patients. Associate Professor Alicia Therese Dennis, Department of Anaesthesia, The Royal Women’s Hospital, Parkville, Australia, reviews peripartum cardiomyopathy in this month’s issue of Anesthesia & Analgesia in the article titled “Heart Failure in Pregnant Women: Is It Peripartum Cardiomyopathy?”
Peripartum cardiomyopathy (PPCM) is defined as heart failure with left ventricular systolic dysfunction quantified by echocardiography. It occurs in about 1:2000 patients, either in the third trimester or in the first months after delivery. Left untreated, mortality can be as high as 50%. Many patients with peripartum cardiomyopathy experience a long-term reduction in cardiac function, particularly if left ventricular end-diastolic diameter is > 60 mm and there is a fractional shortening < 21%.
The etiology of this disease is not clear. To make the diagnosis one must exclude other causes such as fluid overload, tachyarrhythmias, hypertensive heart disease, severe anemia, thyrotoxicosis, sepsis, drug toxicity (including cocaine use), valvular heart disease, congenital heart disease, and prior cardiomyopathy (idiopathic, chemotherapy-associated, and human immunodeficiency virus-associated cardiomyopathy). Risk factors include advanced maternal age or teenage pregnancy, African ethnicity, pregnancy with multiple fetuses, family history, and multiparity (although PPCM occurs for most women with the first or second pregnancy). However, some patients have no risk factors. Early intervention can lessen the chance of developing overt heart failure. Standard management around the time of delivery, including IV fluid therapy and use of oxytocin, can put patients with this disease at increased risk of developing heart failure.
Patients with PPCM can present with orthopnea, dyspnea, cough, swelling, excessive weight gain, and palpitations. It’s important to use echocardiography to differentiate this disease from respiratory disease, particularly asthma. Echocardiographic findings include ventricular dilatation and hypokinesia. If echocardiographic findings include preserved ejection fraction, the patient most likely has another cause of heart failure which may include hypertensive heart failure, or valvular heart disease, not peripartum cardiomyopathy.
There is no specific treatment for the disease. Management is symptomatic and needs to be multidisciplinary including cardiologists. Beta-adrenergic blockade with metoprolol should be considered when the patient is stabilized. Database development might help us better understand the epidemiology of the disease.
This is an excellent review of an important topic. It is increasingly clear that cardiovascular disease, especially cardiomyopathy and hypertensive disorders, is a major cause of maternal morbidity and mortality. While peripartum cardiomyopathy is rare, delays in diagnosis are common and contribute to adverse maternal outcomes. With improved recognition the obstetric and anesthesia teams have the potential to improve maternal outcomes.