Los Angeles, CA- Heart failure associated with pregnancy has been described as a distinctive form of cardiomyopathy for many years. Pregnancy-associated cardiomyopathy (PACM) presented in the peripartum period  was later defined as peripartum cardiomyopathy (PPCM). Classical criteria for diagnosis of PPCM limited the diagnosis to the last gestational month and first 5 months after delivery. A study published in the April 26, 2005 issue of Circulation by Uri Elkayam, MD et al from the University of Southern California Keck School of Medicine further defined the clinical profile of PPCM. They also compared the clinical characteristics of patients who meet traditional criteria of PPCM with those diagnosed with cardiomyopathy earlier during pregnancy.

Data was obtained from 123 women with a history of cardiomyopathy during pregnancy or postpartum period. One hundred women met traditional criteria for peripartum cardiomyopathy, while 23 were diagnosed with pregnancy-associated cardiomyopathy earlier than the last gestational month.

Peripartum cardiomyopathy patients had a mean age of 31 +/- 6 years and were mostly white (67%).  These patients were also found to have associated conditions such as gestational hypertension (43%), tocolytic therapy (19%) and twin pregnancy (13%). Left ventricular ejection fraction at the time of diagnosis was 29+/-11% and improved to 46+/- 14% (P<0.0001) at follow-up. Maternal Mortality was 9%.

The study made a comparison between PPCM and early PACM groups, showing no statistically significant difference in age, race, associated conditions, left ventricular ejection fraction at diagnosis, its rate and time of recovery and maternal outcome between the two groups.

Overall, the study demonstrated a higher incidence of PPCM in women greater than 30 years of age. They showed that PPCM was not limited to black women, which was proposed in previous studies. Multiparity did not seem to be a risk factor for PPCM, as 40% of the cases were during the patient’s first pregnancy. The study also showed a strong association between PPCM and gestational hypertension and twin pregnancies. This association between hypertension and PPCM, may indicate that increased blood pressure may be a cause of heart failure in these patients. The association between twin pregnancies and PPCM may support an autoimmune mechanism for PPCM due to increased amount of cell trafficking during gestation. The high incidence of  PPCM in tocolytic therapy may suggest long-term use of terbutaline tocolysis as a cause of the cardiomyopathy.

The study also showed that almost 20% of the patients developed symptoms and diagnosis of heart failure earlier than the last gestational month. Thus, clinicians should be aware of the possibility of early presentation of PACM such that a timely course of treatment and management can follow diagnosis.

Co-Authors: Mohammed W. Akhter, MD; Harpreet Singh, MD; Salman Khan, MD; Fahed Bitar, MD; Afshan Hameed, MD; Avraham Shotan, MD