Peripartum cardiomyopathy: Current therapeutic perspectives

Abstract

Peripartum cardiomyopathy is a rare condition of unclear etiology that accounts for an important percentage of pregnancy-related deaths. Deaths from peripartum cardiomyopathy can be attributed to profound left ventricular failure, thromboembolic events, or arrhythmia. Prompt recognition of the condition, initiation of appropriate medical management, collaboration with perinatology for delivery management, referral to cardiac transplant centers when necessary, and counseling regarding future pregnancies is required for a successful outcome. Patients should be diagnosed by clinical evaluation and echocardiography. After establishing left ventricular dysfunction, a standard heart failure medical regimen should be instituted. Hospitalization should be considered for patients with class III or greater symptoms, or for those patients not responding to outpatient management. If the diagnosis is made in the antepartum period, delivery should be strongly considered. Endomyocardial biopsy has low yield in this situation and should not be considered standard care, especially because controversy exists over the effectiveness of immunosuppressive therapy for myocarditis. Selenium, pentoxifylline, and immune globulin have all been shown to have a beneficial effect in small series of patients. The addition of these agents to standard therapy, however, should be considered on a case-by-case basis. Anticoagulation should be considered in patients with ejection fractions less than 35%. Transplantation results in survival comparable to women with idiopathic-dilated cardiomyopathy, and should be pursued in the appropriate setting. Future pregnancies should be discouraged, even if the left ventricular function recovers. Significant improvement in ventricular function can be expected in up to 50% of patients.