MRCP PART-2 WRITTEN COURSE:
PPCM affects 1 in 3,000 live birth pregnancies. The aetiology is unknown but the condition is much more common in African women. Other predisposing factors include advanced age, multiple pregnancy, multi-parity and a history of hypertension in pregnancy.
The condition presents in the last month of pregnancy or within five months post delivery, whereas females with Idiopathic-DCM present in the second trimester when the burden of volume overload is greatest.
Diagnosis requires the following four criteria:
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Presentation in the last month or within five months of delivery.
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Absence of an obvious cause for heart failure.
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Previously normal cardiac status.
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Echocardiographic evidence of systolic left ventricular dysfunction.
The Management is with conventional heart failure therapy. ACE inhibitors should be avoided during pregnancy. Patients with very dilated or poorly contracting left ventricles should be anticoagulated, as the risk of intramural thrombus is high in PPCM.
The prognosis is guarded with up to 25% offemales dying in the first three months. Approximately 50% recover full cardiac function within six months. Around 5% of females require cardiac transplantation. Future pregnancies should be avoided in females who have not recovered normal cardiac size and function.
SsBox: Peculiarities in the management of Acute Heart Failure caused by PPCM-
· Multidisciplinary approach with focus on health of mother and foetus.
· Avoidance of heart failure (HF) drugs with foetal toxicity during pregnancy (i.e. ACE -Is/ARBs, AAs (ALD Antagonists) mineralocorticoid receptor Antagonists) and breastfeeding; thereafter standard HF therapy.
· Consideration of Bromocriptine (2.5 mg twice daily for 2weeks, followed by 2.5 mg per day for 6 weeks) in addition to standard HF therapy.
· Anticoagulation with Heparin to avoid cardioembolic complications in patients with LVEF ≤35% or treated withbromocriptine (if no contraindication exists).
· In the case of Cardiogenic Shock, consideration of Levosi-Mendan (0.1μg/kg/min for 24 h) instead of catecholaminesas First-line inotropic drug. Early transfer to experienced centre. Early evaluation of mechanical circulatory support according to the centre’s experience.
· Prevention of SCD, early consideration of AICDin patients with LVEF ≤35%.