Peripartum cardiomyopathy-recurrence risk
A 29-year-old female G1P1 who is currently contemplating pregnancy but had history of permpartum cardiomyopathy/HF with improved (LVEF 30% in early 2019 >> improved to 50% @ the end of 2019 ).
3 months postpartum in early 2019, reported dyspnea with leg swelling with echo showed LVEF 30%. Improved with medical management and currently NYHA class I with recent echo showed LVEF 50%. On losartan, spironolactone and carvedilol.
She is willing to take risk even if she ended up in cariogenic shock requiring mechanical circulatory support.
I want to hear other members opinion how to approach the case during pregnancy and postpartum as well.
Would you support frequent echos? No lactation?
Thank you Mansour for your case ..
I have a question...
Did she underwent doubatime stress ECHO before deciding whether she can tolerate another pregnancy???
So you will stop losartan, spironolactone, continue with B blocker, and closely observe her clinically, really I have no idea regarding Echo follow up frequency..
For lactation stop losartan, continue with Aldactone.
Tough case @Mansour Khaddr !
I will refer her to one of my Heart failure colleagues and I go and do 2 Pacemakers while he is having a discussion with her...😃
Thank you everyone for your input.
We don’t have heart failure team in our town. The closest is 3-hr away.
We planned to hold off ARB and Aldactone with transition to hydralazine/nitrate if needed while continuing BB.
Hopefully, we will have input from our heart failure colleagues.
Tough case Dr.Mansure, she had a full recovery, but her initial EF was 30%; I suggest before attempting, we drop her anti-failure treatment keeping only BB, and observe for any signs of relapse for 1-2 months; if not, then close monitoring during pregnancy Echo every four weeks starting 20th wk and every two weeks starting 30th wk
A team approach with cardiology maternity, Obs/Gyn regarding the use of the method of delivery, use of Bromocriptine, ICU, and support if she has an unfortunate recurrence
@Mansour Khaddr @Salah Elbadri sounds like a great plan.
Do we have clear guidelines from ACC/AHA or ECS on situations like this? I suspect mostly will be LOE "C"..
This is not a straight forward question in a sense that there is no data or evidence to guide your decision. Nothing but expert opinions.
The fact that she had an improved EF is reassuring, but her risk of relapse remains higher than the general population.
Termination of pregnancy will not prevent this replase. So that will not be recommended unless of preferred by the patient.
You are forced to stop ACE/ARB and spironolactone. You can continue beta blockers (perhaps switching to a more cardioselective agent like metoprolol succinate will make sense - again no data to support)
I would not recommend vasodilator therapy like hydral/ISDN unless needed to control high BP.
Counseling is key. Knowing the risks before getting pregnant is important.
No strong data to support stress test to check for contractile reserve but in my opinion will not be useful in this scenario. I would not recommend getting one.
An absolute must is involving MFM, high risk OB and planning for delivery location, mode, timing and preparation for mechanical support if she progresses to shock peripartum.
Baseline echo with strain imaging and serial echocardiograms every trimester for the 1st 2 trimesters and monthly in the 3rd trimester or at anytime if HF symptoms start to occur. BP and blood sugar control needs to be strict.
And hope for the best....
She is someone who will benefit from bromocriptine therapy after delivery (more data to come on that in few years we are part of a RCT to study bromocriptine in peripartum cardiomyopathy)
I hope this is helpful
I had a couple of cases like this recently and my approach is pragmatic .. if they understand the risk and still want to go ahead with the pregnancy, first manage them in MDT in conjunction with their obstetrician, switch them to only metoprolol succinate as high dose as they can tolerate. Echo and Nt pro BNP 4 weekly from third trimester or earlier if symptomatic. Aim for elective CS .
- LV didn't recover completely to normal ( bad start ). advice against ..
- Treadmill stress echo test ( not Dobutamine ) for risk stratification . IF LV get dilated or LV strain get worst compared to resting . High risk of cardiomyopathy. advice against pregnancy.
- After all ( a mother with one kid is better than 2 kids without a mother )
Thank you all 🙏 for your feedback/help to manage the case. I will keep you posted with what happen next year ISA.
Something will be resonating in my mind "a mother with one kid is better than 2 kids without a mother".