Peripartum cardiomyopathy

Symptoms

Peripartum cardiomyopathy (PPCM) usually occurs during late pregnancy or the months after delivery. Some symptoms can seem like changes that naturally happen during pregnancy or after delivery. For example, you may feel very tired.

PPCM symptoms happen when the heart can't pump blood as it should. The condition causes symptoms of heart failure. Symptoms can include:

• Shortness of breath or trouble breathing with activity or even at rest.
• Trouble breathing when you lie flat.
• A cough while lying down.
• Feeling very tired, even after getting rest.
• Swelling in your legs, ankles or feet.
• Fast or pounding heartbeats.
• Fainting or feeling dizzy or lightheaded.
• Chest discomfort or pain, mostly after physical activity or heavy meals.

In some people, the symptoms get worse quickly.

When to seek care

Call your healthcare professional if you are pregnant or recently gave birth and have any of these symptoms:

• Shortness of breath that is new or getting worse.
• Chest discomfort.
• Fast or pounding heartbeats.
• Swelling that is new or getting worse.

When to seek emergency care

Peripartum cardiomyopathy (PPCM) can cause heart failure.

Call 911 or your local emergency number if you have symptoms such as:

• Severe weakness.
• Sudden, severe shortness of breath or very fast breathing.
• Chest pain that is not explained or lasts for more than a few minutes.
• Very fast or pounding heartbeats with shortness of breath, chest pain or fainting.
• Weak pulse.
• Low blood pressure.
• Urinating less than usual or not at all.

These symptoms may happen when the heart can't pump blood as it should. But there are many other possible causes. At the emergency room, healthcare professionals do tests to learn if your symptoms are due to heart failure or something else.

Risk factors

Some things make you more likely to get peripartum cardiomyopathy. But having a risk factor does not mean that you will definitely develop PPCM. Some risk factors cannot be changed.

Risk factors for peripartum cardiomyopathy may include:

• Preeclampsia, a pregnancy complication that involves high blood pressure, high levels of protein in the urine and signs of organ damage.
• High blood pressure during pregnancy.
• Pregnancy with twins or other multiples.
• Being age 30 or older during pregnancy.
• Some gene changes, especially changes in a gene called TTN.
• Not having enough healthy red blood cells, called anemia.
• Race. PPCM is much more likely to develop in Black women than it is in white women.

Prevention

If you are pregnant, go to all your pregnancy care visits. Tell your healthcare professional about any new symptoms or if any symptoms get worse. If you have had PPCM before, talk with your cardiologist and pregnancy care team before another pregnancy. PPCM can come back during a future pregnancy.

Treatment

If you have peripartum cardiomyopathy (PPCM), a team of healthcare professionals work together to treat your condition and support your care. You do not have to manage the condition on your own. Your healthcare team depends on your specific needs but may include:

• A doctor trained in pregnancy and childbirth, called an obstetrician.
• A doctor trained in high-risk pregnancies, called a maternal-fetal medicine specialist.
• Doctors trained in heart conditions, called cardiologists.
• Heart failure specialists.
• A primary healthcare professional.

The goals of peripartum cardiomyopathy (PPCM) treatment are to:

• Manage symptoms.
• Keep the condition from getting worse.
• Lower the risk of complications.

The type of treatment depends on:

• The type of cardiomyopathy and how serious it is.
• How weak your heart is.
• Whether you are pregnant or just had your baby.

Medicines

Many types of medicines are used to treat peripartum cardiomyopathy (PPCM). Medicines can help:

• Improve blood flow and help the heart pump better.
• Lower blood pressure.
• Slow heart rate.
• Remove extra fluid and sodium from the body.
• Prevent blood clots.

Medicines for PPCM may include:

• Diuretics. These medicines help your body get rid of extra fluid.
• Beta blockers. These medicines slow the heartbeat. They can help the heart pump better.
• Medicine that widens blood vessels. These medicines make it easier for the heart to pump blood through the body. They include hydralazine and isosorbide dinitrate. The medicines may be given separately or combined in one pill.
• A blood thinner called heparin. This medicine helps prevent blood clots. You may need it if you are at a high risk of blood clots. A weak heart can raise the risk of blood clots.
• Bromocriptine. This medicine is used to treat Parkinson disease, type 2 diabetes, high prolactin levels and some other conditions. It may be used for some people with severe PPCM. But it is still being studied as a treatment for PPCM.

Some heart failure medicines can harm a developing baby. These include ACE inhibitors and angiotensin 2 receptor blockers, called ARBs. They are not used during pregnancy. Your care team carefully chooses medicines that fit your needs during pregnancy. The team also considers if you are breastfeeding. Some medicines that are not used during pregnancy, such as some ACE inhibitors, may be used while breastfeeding. Talk with your care team about your treatment and feeding plans.

Heart devices

Some people with peripartum cardiomyopathy (PPCM) may need a heart device. A very weak heart can cause dangerous heartbeat changes. A heart device may help control these changes or help the heart pump blood.

Heart devices include:

• Implantable cardioverter-defibrillator (ICD). This device is placed in the chest. It constantly watches the heartbeat. The device gives an electric shock if needed to stop a dangerous heartbeat. Some people may get a temporary defibrillator that can be worn outside the body instead while the healthcare team waits to see if the heart gets stronger. This is called a wearable cardioverter-defibrillator.
• Pacemaker. A pacemaker prevents the heart from beating too slowly. The device is placed under the skin near the collarbone.
• Cardiac resynchronization therapy (CRT). This is a treatment for some people who have heart failure. It helps the lower heart chambers squeeze at the same time. This helps the heart better pump blood to the body.
• Ventricular assist device (VAD). A VAD helps pump blood from the lower chambers of the heart to the rest of the body. It's a treatment for a weakened heart or heart failure. A VAD may be used to help the heart work while waiting for other treatments, such as a heart transplant.

Cardiac ablation

Some people with severe peripartum cardiomyopathy (PPCM) may have dangerous changes in their heartbeat. They may need a treatment called cardiac ablation. Ablation is not a treatment for PPCM itself.

During ablation, a doctor places one or more catheters into blood vessels to the heart. Sensors at the catheter tips use heat or cold energy to create tiny scars in the heart. The scars block signals that cause irregular heartbeats.

Heart transplant

A heart transplant is surgery to replace a damaged heart with a healthy heart from a person who is no longer living.

Most people with PPCM do not need a heart transplant. It may be an option if PPCM causes severe heart failure and the heart does not get better with other treatments. Some people may have a ventricular assist device (VAD) to help the heart pump while waiting for a transplant.

A transplant may improve quality of life. However, some people who have a heart transplant for PPCM may have a somewhat lower chance of survival after transplant than people who get a transplant for other heart conditions.

Talk to your pregnancy heart team and heart doctors about the risks and benefits of all PPCM treatments.

Labor and delivery

If you have peripartum cardiomyopathy (PPCM) while you are pregnant, your heart and pregnancy care teams work with you to plan your labor and delivery. Your treatment and care depend on how well your heart is pumping. They also depend on how you and your baby are doing.

If you and the baby are doing well, vaginal delivery is usually recommended. A C-section may be needed if your condition gets more serious or for other pregnancy reasons.

During labor and delivery, your healthcare team usually:

• Watches you closely. Your blood pressure, heartbeat, breathing and fluid levels are typically checked.
• Watches your baby's heartbeat. Your baby's heart rate may be watched continuously during anesthesia, labor and delivery. This is called continuous fetal heart rate monitoring.
• Gives you medicine for pain. You may get pain medicine through a small tube placed in your lower back. This is called an epidural. It can help keep labor pain from putting extra strain on your heart.
• Helps with pushing, if needed and if you're having a vaginal delivery. Sometimes, forceps or a vacuum device may be used to help deliver the baby. This can make the pushing part of labor shorter. It also can put less stress on your heart.

After delivery, you need regular checkups by a healthcare professional. Changes in blood flow and body fluids after birth can put extra strain on a weak heart.

Prognosis

The outlook for peripartum cardiomyopathy (PPCM) is different for each person. Many people get better over time. The heart often gets stronger during the first few months of treatment.

But for some people, it takes longer. The heart may stay weak. Black women are less likely than white women to have the heart get back to its earlier strength. The reasons are not fully known. Changes in genes or things in the environment may play a part. Black women also may be diagnosed later after giving birth. This delay may affect how well the heart recovers.

How well the heart pumps when PPCM is found can give your healthcare team clues about how much it may improve.

Future pregnancies

If you've had peripartum cardiomyopathy (PPCM), the condition can happen again during a future pregnancy. Your chance is higher if your heart is still weak before getting pregnant again. But PPCM can come back even if the heart has improved.

Talk with your cardiologist and pregnancy care team before planning another pregnancy. Tests can be done to see how well your heart is pumping. Together, you and your healthcare team can talk about what another pregnancy may mean for you.

Preparing for an appointment

If you think you may have peripartum cardiomyopathy or are worried about your risk, see your healthcare professional. You might first see your pregnancy healthcare professional. You also may be sent to a heart doctor, called a cardiologist.

Here's information to help you get ready for your appointment.

What you can do

When you make the appointment, ask if there's anything you need to do in advance. For example, you may be told not to eat or drink for a short while before some blood tests.

Make a list of:

• Your symptoms. Include any that may not seem related to your heart. Note when your symptoms began.
• Important personal information. Include any family history of cardiomyopathy, heart disease, stroke, high blood pressure or diabetes. Also note any major stresses or recent life changes.
• All medicines, vitamins or other supplements you take. Include those you bought without a prescription. Include the doses.
• Questions to ask your healthcare team.

Take a family member or friend along if you can. This person can help you remember the information you're given.

For cardiomyopathy, some basic questions to ask your healthcare professional include:

• What's the most likely cause of my symptoms?
• What are other possible causes?
• What tests do I need?
• What treatment options are available, and which do you recommend for me?
• Can I breastfeed?
• What should I know about a future pregnancy?
• How often do I need heart tests?
• Should I or my family members have genetic testing?
• I have other health conditions. How can I best manage these conditions together?
• Is there any information that I can take home with me? What websites do you recommend?

What to expect from your doctor

Your healthcare team is likely to ask you questions such as:

• Do you have symptoms all the time, or do they come and go?
• On a scale of 1 to 10, with 10 being the worst, how bad are your symptoms?
• What, if anything, makes your symptoms better?
• What, if anything, makes your symptoms worse?