ObstetricsTier 2Disease (DEADMAN)

Cardiac complications of pregnancy, such as peripartum cardiomyopathy

Description

Pregnancy imposes a major haemodynamic load (cardiac output rises ~30-50%, peaking in the third trimester and immediately postpartum) that can unmask or precipitate cardiac disease
Peripartum cardiomyopathy (PPCM) - a dilated cardiomyopathy presenting from late pregnancy to 5 months postpartum, in a woman without prior heart disease and with no other identifiable cause of heart failure

PPCM incidence varies widely by population (roughly 1:1,000 to 1:4,000 in most series, higher in parts of Africa)
Risk factors: multiple pregnancy, pre-eclampsia/hypertension, maternal age extremes, African ancestry, multiparity

Leading hypothesis: unbalanced oxidative stress -> cleavage of prolactin into an antiangiogenic, cardiotoxic 16kDa fragment -> endothelial and cardiomyocyte damage (the basis for bromocriptine as an emerging therapy)
Other pregnancy cardiac stressors: pre-existing valvular disease (mitral stenosis tolerates pregnancy poorly), congenital heart disease, arrhythmia (SVT more frequent), aortopathy (Marfan, bicuspid valve - dissection risk peaks peripartum)

PPCM: echocardiographic LVEF <45% presenting in the defined time window, with other causes excluded
Symptoms (dyspnoea, oedema, orthopnoea) overlap with normal late pregnancy - maintain a high index of suspicion, especially if symptoms are severe or out of proportion

Standard heart failure therapy adapted for pregnancy/lactation safety - avoid ACEi/ARB/MRA/sacubitril-valsartan antenatally (switch to hydralazine/nitrates); beta-blockers are safe; diuretics as needed
Bromocriptine - emerging adjunct in PPCM (inhibits prolactin cleavage) alongside standard therapy and anticoagulation (LV thrombus risk with very low EF)
High-risk valvular/congenital disease - pre-conception risk stratification (mWHO classification) and planned multidisciplinary care through pregnancy

Pre-eclampsia (shared vascular/anti-angiogenic pathway), multiple pregnancy, hypertension

PPCM - around half recover normal LV function, often within 6-12 months; those who do not recover have high recurrence and mortality risk with a future pregnancy -> subsequent pregnancy generally discouraged if LVEF has not normalised

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