During pregnancy, your body’s cardiovascular system, which includes your heart and all of your blood vessels, undergoes some pretty dramatic changes. Your cardiac output (the amount of blood pumped through your heart in a minute), heart rate, and blood volume all increase, and your blood pressure fluctuates depending on where you are in your pregnancy. Your body adapts to pregnancy, and your heart works hard to make sure you and your baby are getting sufficient blood flow. Rarely, however, a serious heart condition called peripartum cardiomyopathy can develop during pregnancy.
What is peripartum cardiomyopathy?
Peripartum cardiomyopathy (PPCM) is an uncommon but serious type of heart failure that occurs in the final month of pregnancy and up to five months postpartum. It is also called postpartum cardiomyopathy. According to the American Heart Association, PPCM is rare in the United States, occurring in approximately 1,000–1,300 women every year. The CDC indicates that PPCM is responsible for approximately 11 percent of pregnancy-related deaths.
PPCM is a diagnosis of exclusion, which means a diagnosis of PPCM occurs only after all other causes of heart failure have been ruled out.
PPCM is a diagnosis of exclusion, which means a diagnosis of PPCM occurs only after all other causes of heart failure have been ruled out. PPCM is a dilated form of heart failure, in this case often causing the left ventricle of the heart to dilate and enlarge. The left ventricle ejection fraction (LVEF) is the amount of blood pumped out by the left ventricle of the heart with each heartbeat. A normal LVEF is between 55 and 70 percent.
In general, the diagnosis criteria for PPCM are:
- Heart failure after 36 weeks gestation/within five months of delivery
- No other identifiable cause for heart failure
- LVEF of less than 45 percent
What causes PPCM? What are the risk factors?
The cause of PPCM is still being studied, but it is suspected that a wide range of factors including genetics, hormones, prolactin processing (the hormone behind milk production), inflammation, and autoimmune causes may be involved. Note that, generally speaking, as long as a woman is clinically stable and it works with her treatment regimen, she should not be discouraged from breastfeeding.
A big question that can arise after a woman has been diagnosed with PPCM is whether it’s safe to have another baby.
Risk factors for PPCM include:
- History of cardiac disorders
- History of preeclampsia, eclampsia, or postpartum hypertension
- Multiple gestation (carrying more than one baby)
- Obesity
- Chronic hypertension
- Multiple pregnancies
- African descent
- Maternal age greater than 30
- Maternal drug use, specifically: smoking, excessive alcohol consumption, cocaine use
- Long-term use (more than four weeks) of certain tocolytic therapies (to prevent preterm labor)
What are some of the signs and symptoms of PPCM?
Some of the most common signs and symptoms of PPCM are:
- Shortness of breath, especially with exertion and when lying down
- Shortness of breath that wakes you up at night
- Cough (by itself or coughing up blood)
- Swelling of ankles and feet
- Heart palpitations
- Fatigue
- Lightheadedness
- Chest pain
Of course, many of these signs and symptoms occur in healthy pregnancies (hello, cankles!), and you should always run any concerning signs or symptoms by your medical provider.
Diagnosis, Treatment, and Recovery
If your provider suspects you might have PPCM, they will likely order blood work and an echocardiogram, which is an ultrasound of the heart. Often called an “echo” for short, this evaluation can show how your heart is functioning, how well it is pumping blood, and if there are any structural anomalies. While PPCM is a very serious condition, the good news is that with management, recovery usually occurs within three to six months. If you do develop PPCM, your providers will continue to monitor your heart’s function after your pregnancy to determine if you need continued treatment.
If your provider suspects you might have PPCM, they will likely order blood work and an echocardiogram, which is an ultrasound of the heart.
Treatment is often similar to that for others diagnosed with heart failure, and the focus is primarily on improving heart function and managing symptoms, as well as safely delivering your baby if PPCM is diagnosed before delivery. There are many medicines used to manage heart failure symptoms, and there are variations on standard treatments that are safe for pregnancy and breastfeeding. If you are diagnosed with PPCM and are currently breastfeeding (or planning to), it is important to discuss this with your provider.
Some common classes of medications used to treat PPCM are:
- ACE inhibitors (help the heart pump more efficiently)
- Beta blockers (slow down your heart rate so your heart has more time to recover between beats)
- Diuretics (reduce fluid retention)
- Anticoagulants (help thin the blood and prevent blood clots)
If PPCM is diagnosed during pregnancy, decisions regarding delivery of the baby, including timing and vaginal vs. C-section deliveries, are typically made by evaluating many factors like severity of the PPCM, gestational age of the baby, how well the PPCM is being managed, and if you or your baby have any other complications (such as preeclampsia). If mother and baby are both stable, early delivery is not always necessary, but in severe cases, an emergency C-section may be required.
What about another baby?
Like many pregnancy-related conditions, after having PPCM once, the risk is higher that the condition will recur in a future pregnancy. A big question that can arise after a woman has been diagnosed with PPCM is whether it’s safe to have another baby. According to Johns Hopkins Medicine, the answer depends in great part on how well the mother’s heart recovers. If the mother’s heart does not fully recover from PPCM, another pregnancy is typically not recommended. If her heart has returned to full function, any additional pregnancies would likely be monitored closely, and some evaluation prior to planning to conceive may be recommended.
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