Difference between revisions of "Peripartum cardiomyopathy"

(Text replacement - "*Tintinalli" to "")
 
(23 intermediate revisions by 6 users not shown)
Line 1: Line 1:
 
==Background==
 
==Background==
*Disease earlier than last month of pregnancy is likely the same process of HF
+
*Uncommon cause of [[heart failure]]
 +
*Incidence: 1:968 to 1:4000 in the United States<ref>Sliwa K et al.
 +
Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail. 2010;12(8):767. PMID:
 +
20675664</ref>
  
==Diagnosis==
+
==Clinical Features==
*Presentation similar to typical [[CHF]]
+
*Peripartum with presentation similar to typical [[CHF]]
*4 criteria needed to meet definition for PPCM:
+
**Usually occurs in last month of pregnancy or first five months postpartum
**Development of heart failure in last month of pregnancy or w/in 5mo of delivery
 
**Absence of an identifiable cause for the heart failure
 
**Absence of recognizable heart disease prior to the last month of pregnancy
 
**LV systolic dysfunction, such as LVEF < 45%
 
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
*Respiratory tract infection
+
*[[Pneumonia]]
 
*[[PE]]
 
*[[PE]]
 
*[[MI]]
 
*[[MI]]
Line 20: Line 19:
 
{{Postpartum emergencies DDX}}
 
{{Postpartum emergencies DDX}}
  
==Work-Up==
+
==Evaluation==
#ECG
+
===Workup===
#CXR
+
*[[ECG]]
#CBC
+
*[[CXR]]
#Chemistry
+
*CBC & [[LFTs]]
#TSH
+
**screen for [[thrombocytopenia]] or transaminitis that can be found with severe pre-eclampsia
#TTE
+
*Chemistry
 +
*TSH
 +
*[[Echocardiography]]
 +
**bedside TTE can show LV dilation and LV systolic dysfunction
 +
*[[BNP]]
  
==Treatment==
+
===Diagnosis===
*Treat like usual heart failure (except avoid nitroprusside and ACEI)
+
4 criteria needed to meet definition:<ref>Elkayam U et al. Pregnancy-associated cardiomyopathy: clinical characteristics and a comparison between early and late presentation. Circulation. 2005 Apr 26; 111(16): 2050-5.</ref>
 +
#Development of heart failure in last month of pregnancy or within 5 month postpartum
 +
#No identifiable alternate cause of heart failure
 +
#No pre-existing heart disease
 +
#LV ejection fraction < 45%
 +
 
 +
==Management==
 +
*Treat like usual heart failure  
 +
*Consider anticoagulation if EF <30% during and 2-3mo after delivery; avoid warfarin and DOACs
 +
*If pregnant:
 +
**'''Avoid''' [[nitroprusside]] and [[ACEI]]
 +
**Use of [[phenylephrine]] and [[norepinephrine]] controversial
 +
***Some animal/in vitro studies suggest increased vasoconstriction of uterine arteries may lead to adverse fetal outcome, however evidence of effect on human uterine arteries is limited<ref>Van Nimwegen D, Dyer DC. The action of vasopressors on isolated uterine arteries. Am J Obstet Gynecol. 1974;118(8):1099.</ref> <ref>Branco D, Caramona M, Martel F, de Almeida JA, Osswald W. Predominance of oxidative deamination in the metabolism of exogenous noradrenaline by the normal and chemically denervated human uterine artery. Naunyn Schmeidebergs Arch Pharmacol. 1992 Sep;346(3):286-93.</ref>
 +
***Maternal hypotension is bad for both mother and fetus!
 +
**Consider fetal monitoring to assist in evaluating uterine perfusion
 +
 
 +
==Disposition==
 +
*Admit
 +
 
 +
==Prognosis<ref>Bhattacharyya A et Al. Peripartum Cardiomyopathy: A Review. Tex Heart Inst J. 2012; 39(1): 8–16.</ref>==
 +
*Mortality rate up to 10%
 +
*High risk of recurrence in subsequent pregnancies
 +
*Many patients recover within 3 to 6 months of disease onset
  
 
==See Also==
 
==See Also==
Line 37: Line 62:
 
==References==
 
==References==
 
<references/>
 
<references/>
 
*Elkayam U et al. Pregnancy-associated cardiomyopathy: clinical characteristics and a comparison between early and late presentation. Circulation. 2005 Apr 26; 111(16): 2050-5.
 
  
 
[[Category:Cardiology]]
 
[[Category:Cardiology]]
 
[[Category:OBGYN]]
 
[[Category:OBGYN]]

Latest revision as of 19:38, 21 August 2019

Background

  • Uncommon cause of heart failure
  • Incidence: 1:968 to 1:4000 in the United States[1]

Clinical Features

  • Peripartum with presentation similar to typical CHF
    • Usually occurs in last month of pregnancy or first five months postpartum

Differential Diagnosis

Cardiomyopathy

3rd Trimester/Postpartum Emergencies

Evaluation

Workup

Diagnosis

4 criteria needed to meet definition:[2]

  1. Development of heart failure in last month of pregnancy or within 5 month postpartum
  2. No identifiable alternate cause of heart failure
  3. No pre-existing heart disease
  4. LV ejection fraction < 45%

Management

  • Treat like usual heart failure
  • Consider anticoagulation if EF <30% during and 2-3mo after delivery; avoid warfarin and DOACs
  • If pregnant:
    • Avoid nitroprusside and ACEI
    • Use of phenylephrine and norepinephrine controversial
      • Some animal/in vitro studies suggest increased vasoconstriction of uterine arteries may lead to adverse fetal outcome, however evidence of effect on human uterine arteries is limited[3] [4]
      • Maternal hypotension is bad for both mother and fetus!
    • Consider fetal monitoring to assist in evaluating uterine perfusion

Disposition

  • Admit

Prognosis[5]

  • Mortality rate up to 10%
  • High risk of recurrence in subsequent pregnancies
  • Many patients recover within 3 to 6 months of disease onset

See Also

References

  1. Sliwa K et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail. 2010;12(8):767. PMID: 20675664
  2. Elkayam U et al. Pregnancy-associated cardiomyopathy: clinical characteristics and a comparison between early and late presentation. Circulation. 2005 Apr 26; 111(16): 2050-5.
  3. Van Nimwegen D, Dyer DC. The action of vasopressors on isolated uterine arteries. Am J Obstet Gynecol. 1974;118(8):1099.
  4. Branco D, Caramona M, Martel F, de Almeida JA, Osswald W. Predominance of oxidative deamination in the metabolism of exogenous noradrenaline by the normal and chemically denervated human uterine artery. Naunyn Schmeidebergs Arch Pharmacol. 1992 Sep;346(3):286-93.
  5. Bhattacharyya A et Al. Peripartum Cardiomyopathy: A Review. Tex Heart Inst J. 2012; 39(1): 8–16.