Subsequent Pregnancy in Peripartum Cardiomyopathy- Is the Answer Always No?

Abstract

Background Peripartum cardiomyopathy (PPCM) is a rare form of heart failure (HF) afflicting 1 in every 968 pregnancies and one of the leading causes of maternal morbidity in the United States. Women with PPCM are often counseled to avoid subsequent pregnancy based on limited data. Preconception evaluation (PCE) with stress echocardiography (SE) may allow clinicians to risk stratify patients with cardiomyopathy (CM) and guide therapies to improve pregnancy outcomes. Methods 40 women with CM, including 24 with PPCM, were referred to our program for either PCE with SE or medical management during a subsequent pregnancy and were categorized as either low or high risk of developing recurrent HF. Serial resting echocardiograms and cardiology clinic evaluation was recommended, medical interventions, change in cardiac function, and maternal and fetal outcomes were monitored. Results 12 PPCM patients had PCE, 6 deemed high risk with close monitoring and medical intervention (initiation of beta blocker or digoxin therapy) for all except one patient who did not follow up as recommended, she subsequently developed recurrent HF within 6 months postpartum. Of the 6 low risk PPCM patients, one developed HF despite being asymptomatic during pregnancy. Four women were started on beta blockade, hydralazine, and digoxin as indicated during cardiology clinic visits, Among all patients with CM, initiation of digoxin during pregnancy was associated with a 67% incidence of augmented EF and 33% subclinical improvement or unchanged EF. None had reduced EF. Discussion PCE may have risk stratification utility not only for PPCM patients, but also other CM cohorts who seek a successful pregnancy. In women with unknown risk, initiation of appropriate medications such as digoxin resulted in improved function and lower risk of maternal or fetal complications.