Peripartum Cardiomyopathy

Peripartum cardiomyopathy is a form of idiopathic systolic heart failure which occurs during the end of pregnancy or the early post-partum in the absence of an identifiable etiology. The exact pathogenesis remains unknown, and the incidence is higher in African ancestry, multiparous and hypertensive women, or older maternal age. Delay in diagnosis is common, mainly because symptoms of heart failure mimic those of normal pregnancy. Echocardiography showing decreased myocardial function is at the center of the diagnosis. Management relies on the general guidelines of management of other forms of non-ischemic cardiomyopathy; however, special attention should be paid when choosing medications to ensure fetal safety. Outcomes can be variable and can range from complete recovery to persistent heart failure requiring transplant or even death. High rates of relapse with subsequent pregnancies can occur, especially with incomplete myocardial recovery. Additional research about the etiology, ...

The second part of the review of peripartum cardiomyopathy includes contemporary
views of a specifics of disease onset. Detailed specifics of the disease onset is
provided according to their specificity and diagnostical value. The approaches to
diagnostics described beginning from physical examination to instrumental
methods. Taking into account of the microparticles role on the disease onset, the
importance ov their measurement is highlighted in peripartum cardiomyopathy,
especially peripheral vasodilators, diuretics, ACE inhibitors, antiarrhythmic drugs,
anticoagulants, pentoxyphilline, bromocryptine, cabergoline. The methods selected
of artificial circulation in severe disease course and the data provided on
plasmapheresis usage and implantable cardioverter-defibrillator. In general the
points of delivery problems discussed.
[In Russian]

Представленный материал посвящен лечению критических состояний при перипартальной кардиомиопатии. В первой части сообщения приводятся данные о клинических проявлениях, диагностике и дифференциальной диагностике острой сердечной недостаточности при этом заболевании. Подчеркивается важность своевременной и адекватной оценки как наличия и выраженности сердечно-легочной недостаточности, так и подтверждения диагноза с применением дополнительных методов исследования. Приводятся протоколы междисциплинарного ведения больных с острой перипартальной кардиомиопатией. Обсуждаются вопросы ведения больных перипартальной кардиомиопатией с сердечно-сосудистой недостаточностью и нестабильной гемодинамикой, а
также роль различных фармакологических препаратов, используемых при этих состояниях, в частности: катехоламинов, диуретиков, левосимендана, бромокриптина и антикоагулянтов.

Abstract.  The presented review concerns management of critical conditions in peripartum cardiomyopathy. In the first part of the article the data about clinical manifestation, diagnostics, and differential diagnosis of acute heart failure as a presentation of the disease are described. A special emphasis is laid on timely and adequate assessment of cardiopulmonary distress, and diagnosis confirmation using additional diagnostic modalities. The interdisciplinary work-up and treatment algorithm for patients with acute peripartum cardiomyopathy are presented. The questions of management of patients with acute peripartum cardiomyopathy with cardiovascular insufficiency and unstable hemodynamics are discussed along with a role of different pharmacologic drugs used in these conditions including catecholamines, diuretics, levosimendan, bromocriptine, and anticoagulants.

Обзор посвящен обсуждению современных представлений о лечении перипартальной кардиомиопатии (ПКМП). В начале обзора приводится определение ПКМП, затрагиваются общие вопросы диагностики и патогенеза заболевания. В частности, обсуждается роль системы «пролактин — катепсин D — пролактин 16 кDa» в развитии кардиомиопатии. Освещаются общие подходы ведения больных. Приводятся детальные сведения о показаниях, осложнениях и клиническом опыте основных фармакологических препаратов, применяемых в лечении ПКМП с учетом их возможного неблагоприятного влияния на плод и лактацию. Дано подробное описание диуретиков, включая петлевые, тиазидового ряда и калийсберегающие препараты. Отмечена относительная безопасность и эффективность нитратов и гидралазина в условиях ограниченного выбора из группы вазодилататоров и, особенно, противопоказанных при беременности ингибиторов ангиотензин-превращающего фермента и блокаторов рецепторов к ангиотензину-II. Отдельное внимание уделено группе инотропных препаратов: левосимендану, милринону и сердечным гликозидам. Описана роль β-адреноблокаторов и ивабрадина в лечении сердечной недостаточности при ПКМП. Подробно представлены антикоагулянты, назначение которых оправдано при выраженной дилатации полостей сердца, снижении фракции выброса и наличии интракардиального тромбоза. В статье обсуждается место антиаритмических препаратов, применяемых при развитии разнообразных нарушений ритма сердца. Данные приведены с учетом потенциального влияния на плод при антенатальной ПКМП, при которой преимущественно назначаются лидокаин и соталол, с осторожностью — аденозин, хинидин и флекаинид и полностью противопоказаны амиодарон и дронедарон. С учетом предложенных патогенетических механизмов, представлена также информация о лекарственных средствах, направленных на коррекцию возможных звеньев механизма развития этой патологии. В частности на основе проанализированных данных обсуждается обоснованность, показания и побочные эффекты иммуносупрессивной терапии, иммуноглобулина, пентоксифиллина, блокаторов секреции пролактина -
бромокриптина и каберголина. Приведен опыт трансплантации сердца у больных с рефрактерной ПКМП, а также затронуты вопросы родоразрешения при этом заболевании. Ключевые слова: перипартальная кардиомиопатия, сердечная недостаточность, лечение, патогенетическая терапия, блокаторы секреции пролактина, терапия сердечной недостаточности при беременности, бромокриптин.
Abstract
The presented review concerns discussion about current insights into treatment of peripartum cardiomyopathy (PCMP). The definition of PCMP and general issues about diagnosis and pathogenesis of the disorder are provided at the head of the review. Particularly, the role of the system "prolactin — cathepsin D — prolactin 16 kDa" in cardiomyopathy development is disclosed. The general approaches to management of the patients are highlighted. The review provides detailed data about indications, adverse effects and derived clinical experience concerning the main pharmacological drugs which had been used in PCMP treatment given their possible unfavorable influence on fetus maturation and maternal lactation. The detailed description is provided on diuretics including loop, thiazide and potassium-sparing drugs. It was noted relative safety and efficiency of nitrates and hydralazine in conditions of limited choice from vasodilator group and, particularly, angiotensinconverting enzyme inhibitors and angiotensin-II receptor blockers which are contraindicated in pregnancy. A special attention is paid to the group of inotropic drugs: levosimendan, milrinone, and cardiac glycosides. The role of β-blockers and ivabradine is disclosed in heart failure treatment of PCMP. Anticoagulants were presented in details given that these drugs are justified in severe cardiac chambers dilation, decrease in ejection fraction, and in presence of intracardiac thrombosis. The place of antiarrhythmic drugs administrating in various cardiac rhythm disorders is discussed in the review. The data is given with account of potential influence on fetus in antenatal PCMP in which lidocaine and sotalol are the most preferable drugs; adenosine, quinidine, and flecainide are useful with caution, but amiodarone and dronedarone are absolutely contraindicated. Taking into account proposed pathogenic mechanisms of this cardiomyopathy, the information about pharmacological drugs directed to correction of possible links of development mechanism of this pathology is introduced. On the basis of analyzed data authors discuss relevance, indications and side effects of immunosuppressive therapy, immunoglobulin, pentoxifylline, and prolactin secretion inhibitors — bromocriptine and cabergoline. The experience of cardiac transplantation is specified in patients with refractory PCMP, and issues of delivery are highlighted in women suffering from this disease.
Key words: peripartum cardiomyopathy; heart failure; treatment; pathogenetic therapy; prolactin secretion inhibitors; heart failure treatment during pregnancy; bromocriptine.

Introduction: Peripartum cardiomyopathy (PKM) is a form of congestive heart failure that results from an enlarging of the heart and a weakening of the heart muscle in the last month of pregnancy and in the first five months of the postnatal period. Major risk factors include pregnancy at >30 years of age, multiparity, chronic hypertension and eclampsia. Patients suffering from PKM generally present with symptoms akin to heart failure, and the condition can be considered normal during the late period of pregnancy. A diagnosis of PKM can be made from anamnesis, a physical examination and echocardiography. Case Presentation: A 34-year old female patient, visiting the family medicine polyclinic for vaccinations of her 1-month-old infant, was noted to be suffering from shortness of breath, palpitations and coughing. There was no medical history of any disease or medication before or during the pregnancy. The patient’s blood pressure was 120/70 mmHg and her pulse was rhythmic at 122/mi...

ABSTRACT Peripartum cardiomyopathy (PPCM) is a specific form of dilated cardiomyopathy, characterized by the development of systolic heart failure in the period between the last month of pregnancy and five months after delivery. It is a rare clinical condition of variable prognosis that occurs in the absence of identifiable cause or prior known heart disease. The authors report a clinical case of a previously healthy 33-year-old woman who developed de novo symptoms of progressively worsening heart failure in the 33rd week of gestation, that ended after two weeks in the development of cardiogenic shock and the need for emergency delivery.

Peripartum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy that presents with heart failure secondary to left ventricular systolic dysfunction. Onset is from the last trimester of pregnancy to 5 months postpartum. Diagnosis in the last trimester is complicated by the fact that the early symptoms of this disorder may mimic the symptoms of normal pregnancy. However, it is essential for the practitioner dealing with such population to have a high degree of clinical suspicion for early diagnosis and management. Echocardiography is used to diagnose this entity and monitor the therapy. We present a case report of a 40-year-old woman who presented two days post-partum with respiratory distress and early echocardiography helped in diagnosing PPCM. The aim of this report is to make health professionals aware of the possibilities of PPCM in a woman with dyspnoea in the postpartum period.