What Is Peripartum Cardiomyopathy (PPCM)?

Peripartum cardiomyopathy (PPCM) is a rare condition that weakens the heart, starting in the last month of pregnancy or within the first five months after the baby's birth.

Signs of PPCM can be easy to miss because they mimic many of the typical symptoms of pregnancy. But a sudden onset of symptoms during or after pregnancy warrants a visit to the doctor.

• Shortness of breath, especially during exercise or when lying down
• Fatigue
• Swelling in the feet and ankles
• Chest pain
• The feeling that your heart is racing or skipping beats (palpitations)
• Dry cough
• Lightheadedness

While the exact cause of PPCM is unclear, certain factors may increase your risk. Common risk factors include:

• Obesity

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• Inflammation of the heart muscle (myocarditis)
• Alcohol or substance use disorder

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• High blood pressure during pregnancy (preeclampsia)

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• Nutrient deficiencies

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• African ancestry

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• Pregnancy after age 30

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• Giving birth to twins or another multiple pregnancy

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Your doctor may use the following tests to diagnose PPCM:

• Electrocardiogram (ECG or EKG) This test evaluates the electrical activity in the heart and may show if the heart function is weak (a sign of cardiomyopathy). But a normal EKG result doesn’t mean you’re in the clear.

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• Blood Tests Your provider may perform a blood test to check electrolytes (minerals that carry an electric charge), kidney and thyroid function, and complete blood count.

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   Your provider may also use a blood test to measure levels of brain natriuretic peptide (BNP), a protein made by the heart and blood vessels. High BNP levels could be a sign that your heart has been damaged by PPCM.

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• Imaging Tests Imaging tests like X-rays (which use electromagnetic waves to create pictures of the inside of your body) can be used to check for fluid in the lungs (which can happen if the heart isn’t pumping strongly enough) and a rapid or abnormal heart rate.

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  But because an X-ray exposes you to small amounts of radiation, your provider may recommend a lung ultrasound during pregnancy.

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  Your provider may also suggest magnetic resonance imaging (MRI), a procedure that uses radio waves and powerful magnets to take pictures of the heart.

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  To do an MRI, your provider injects a contrast dye into a vein to help the heart and surrounding tissues show up clearly in the pictures.

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1. Heart failure develops in the last month of pregnancy or in the months after delivery
2. An ejection fraction (also known as left ventricle ejection fraction; LVEF) of less than 45 percent. This is a measurement of how much blood the heart pumps out of the heart’s lower left chamber, also known as the left ventricle, with each beat. A healthy ejection fraction is between 50 and 70 percent.
3. No other obvious cause for heart failure (as determined by the tests mentioned above)

Medication Options

Medicines used to treat PPCM include:

• Angiotensin Converting Enzyme (ACE) Inhibitors These medications lower blood pressure and help the heart work more efficiently.

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  But ACE inhibitors are unsafe during pregnancy.

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• Angiotensin-Receptor Neprilysin Inhibitors (ARNIs) ARNIs lower blood pressure to ease the workload on the heart.

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  These medications are also unsafe for pregnant people.

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• Anticoagulants PPCM increases the risk for blood clots. Anticoagulants help thin the blood to prevent clots.

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  Certain anticoagulants may be preferred during pregnancy. Low-molecular-weight heparin, for example, is typically recommended for pregnant patients, while warfarin is avoided.

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• Beta-Blockers Beta-blockers make the heart beat more slowly, helping it recover.

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  But beta-blockers can cause health issues for a fetus, so your doctor may suggest an alternative.

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• Bromocriptine This drug blocks prolactin, the hormone that triggers milk production for breastfeeding.

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  Prolactin may contribute to the development of PPCM.

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   Because the research on bromocriptine is still limited, this treatment is somewhat controversial.

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• Diuretics Diuretics, also known as water pills, remove extra fluid from your body to lower blood pressure and reduce the demand on the heart.

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   Research suggests diuretics can be used safely during pregnancy.

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  Check with your healthcare provider to be sure.
• Hydralazine Hydralazine is a vasodilator (a medication that relaxes and widens blood vessels to increase blood flow) that’s safe during pregnancy.

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• Digoxin This medication can also be used to treat PPCM in pregnant patients.

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   It helps stabilize the heart’s rhythm and strengthen heartbeats.

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Surgery

When the heart muscle is weak from PPCM, the risk of developing a life-threatening irregular heartbeat (arrhythmia) increases.

You can avoid PPCM by making heart-healthy lifestyle changes before you become pregnant.

The most effective lifestyle changes to prevent PPCM are:

• Avoid using tobacco products.

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• Eat heart-healthy foods like fruits, vegetables, nuts, whole grains, lean animal protein sources, and fish.

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• Maintain a healthy weight.

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• Exercise regularly.

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• Check your blood pressure often, and treat it if it's high.

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• Use birth control to avoid an unplanned pregnancy.

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• Eat a heart-healthy diet. Eat a low-salt diet that contains lots of fruits and vegetables, whole grains, lean meats, and fish, and limit how much fluid you drink. These steps will lower your blood pressure and improve symptoms.

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• Get regular exercise. Walking, cycling, or doing other moderate aerobic exercise every day can help reduce heart rate and blood pressure and manage your symptoms. Ask your doctor which type of fitness program is safe for you before you start exercising.

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• Weigh yourself daily. Sudden changes in weight from day to day could be a sign that too much fluid is building up in your body and your condition is getting worse. Track your weight and report significant weight changes to your doctor.

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  In general, gaining two pounds in one day or five pounds in one week is considered significant.

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You're less likely to make a full recovery if you:

• Had an LVEF of less than 35 percent at time of diagnosis

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• Are of African ancestry

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• Got pregnant at an older age

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• Were diagnosed more than one month after giving birth

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• Have a lot of inflammation in your body

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When left untreated or poorly managed, PPCM may lead to the following complications:

• Severe heart failure

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• Brain damage

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• Heart arrhythmias

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• Cardiac arrest (when the heart stops beating suddenly)

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• Pulmonary edema (fluid buildup in the lungs)

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• Blood clots

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• Need for a heart transplant

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• Death (while rare, it is more likely in women with a poor ejection fraction and those who need a mechanical heart pump or heart transplant)

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• High Blood Pressure (Hypertension) Hypertension is a condition where the heart consistently has to work harder to pump blood, increasing your risk for heart attack and stroke.

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• Preeclampsia Preeclampsia is high blood pressure that develops during pregnancy (after 20 weeks).

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• Diabetes Diabetes is a chronic disease that occurs when the blood sugar is consistently too high.

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   Diabetes that develops during pregnancy is called gestational diabetes.

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• Arrhythmia This means you have an abnormal heart rhythm. Your heart may beat too fast, too slow, or inconsistently.

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• Thrombosis Thrombosis is a serious condition that happens when a blood clot forms in a blood vessel or in the heart.

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• Thyroid Disorder There are a couple of common conditions that affect the thyroid gland (a butterfly-shaped organ located in the neck that makes hormones that control how your body turns food into energy). Hypothyroidism, also known as an underactive thyroid, happens when the thyroid doesn’t make enough hormones. Hyperthyroidism is an overactive thyroid that makes too many hormones.

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Other people with PPCM can give you the support you need to manage the condition. These organizations offer a variety of PPCM resources and connections to support networks.

Peripartum Cardiomyopathy Network

PCN is a network of doctors, nurse practitioners, physician assistants, and nurses who are involved in PPCM research and treatment. Its website offers information about the condition, support groups, and a directory of PCN providers.

Let’sTalkPPCM

This nonprofit organization raises awareness of PPCM by providing educational resources for healthcare providers, mothers, families, and the general public. It also offers support groups, a mentoring program that pairs newly diagnosed moms with survivors, and virtual assistance for those seeking support from cardiologists, nutritionists, birth workers, and more.

• Peripartum cardiomyopathy is a rare type of heart failure that happens during pregnancy or in the months after delivery.
• In PPCM, the heart muscle weakens and can't pump out as much blood to the body.
• Symptoms like shortness of breath and fatigue may be easy to miss, because they look like typical pregnancy symptoms.
• Medicines can protect the heart and make it easier to pump, but only certain ones are safe to use during pregnancy. Most people recover, although the condition can return during future pregnancies.