Question 15

College answer

Not available.

Discussion

a) Peripartum cardiomyopathy has some specific defining criteria:

• Hear failure in the end of pregnancy, or in the following few months
• No other explanation (diagnosis of exclusion)

This is from the ESC statement from 2010, and is probably enough for a sub-question worth only 20%  of the marks. If one wanted to write a little extra, a previous college answer holds clues to what the college examiners think is a good definition:

• Onset of heart failure in the last month of pregnancy or within 5 months post-partum
• Absence of an identifiable cause of heart failure
• Absence of recognizable heart disease prior to the last month of pregnancy
• LV systolic dysfunction demonstrated by classical echocardiographic criteria. The latter  may be characterized as an LV ejection fraction < 45%, fractional shortening < 30%, or both, with or without an LV end-diastolic dimension 2.7 cm/m2 body surface area.

This definition was generated by a panel of fourteen experts during a conference workshop (Pearson et al, 2000).

b) Five plausible differentials would include:

• Massive PE
• Amniotic fluid embolism
• Worsening of pre-existing rheumatic MR or TR
• Pre-eclampsia or eclampsia
• Pre-existing unrecognized congenital heart disease, unmasked by the volume stress of pregnancy

c) Management is same as you would manage acute heart failure from any cause:

• Management of preload
  • Diuretics, fluid restriction, venodilators
  • Maintenance of sinus rhythm and atrial systolic contribution
  • Pacing to maintain AV synchrony
• Management of afterload
  • Left ventricle
    • Vasodilators
    • Beta-blockers
    • ACE-inhibitors are contraindicated in pregnancy
  • Right ventricle
    • Normoxia and normocapnea
    • Avoidance of excessive postive respiratory pressures
    • Pulmonary vasodilators
• Management of contractility
  • Inotropes
    • Dobutamine
    • Milrinone
    • Levosimendan
  • Cardiac resychronisation
  • Supportive hormones and micronutrients (cortisol, insulin, calcium, glucagon, thyroxine, thiamine etc)
• Cheating
  • Increase cardiac output by unnatural means:
    • IABP
    • LVAD
    • ECMO
    • Increase the pacemaker rate
• Planning for delivery and the future:
  • Steroids to help foetal lung maturation, in case something happens
  • Instructions not to breastfeed (prolactin secretion can make PPCM worse)
  • Instructions to avoid getting pregnant again
  • Consider referral for transplant, if LV function fails to improve