KEY FACTS OF Peripartum Cardiomyopathy - PPCM

Peripartum Cardiomyopathy (PPCM): The Heart Condition Every Clinician Should Recognize

Pregnancy is often described as a physiological stress test for the body. While most women adapt remarkably well, a small number develop a rare but potentially life-threatening cardiac condition known as Peripartum Cardiomyopathy (PPCM). Despite improved awareness, PPCM continues to be underdiagnosed—mainly because its symptoms mimic normal pregnancy-related discomforts.

In this article, we explore what PPCM is, how it presents, why it happens, and why early recognition makes all the difference.

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What Is Peripartum Cardiomyopathy?

Peripartum cardiomyopathy is an idiopathic form of heart failure characterized by left ventricular systolic dysfunction that develops during a very specific period:

**✔ From the last month of pregnancy

✔ To up to 5 months after delivery**

Women must not have had any prior structural heart disease, and the LVEF is typically <45%.

It is considered a diagnosis of exclusion, meaning other causes of cardiomyopathy—ischemic, valvular, hypertensive, viral, or genetic—must be ruled out.

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Why Does PPCM Occur?

The exact cause remains a blend of multiple theories. Current evidence points to:

Hormonal stress (prolactin fragments with cardiotoxic properties)

Oxidative stress and vascular dysfunction

Autoimmune or inflammatory processes

Genetic susceptibility (in some families, mutations overlap with dilated cardiomyopathy)

Overall, pregnancy imposes enormous hemodynamic and metabolic demands on the heart, and in susceptible women, this may unmask vulnerability to myocardial injury.

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Who Is at Higher Risk?

Some women are more prone to PPCM. Key risk factors include:

Advanced maternal age

Multiparity

Preeclampsia or gestational hypertension

Multiple gestation (twins, triplets)

African or South-Asian ethnicity

Use of tocolytics

Selenium deficiency or poor nutritional status

Smoking or substance use

Awareness of these risk factors can help clinicians identify symptoms early.

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Common Symptoms to Watch For

Symptoms often overlap with normal pregnancy, which is why PPCM is commonly missed. However, the following features should raise suspicion:

New-onset dyspnea, orthopnea, paroxysmal nocturnal dyspnea

Persistent cough, especially nocturnal

Fatigue and reduced exercise tolerance

Palpitations or tachyarrhythmias

Peripheral edema out of proportion to normal pregnancy

Chest pain (less common)

Syncope

When these symptoms occur in the late pregnancy or postpartum period, PPCM should always be on the differential.

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How Is PPCM Diagnosed?

The cornerstone of diagnosis is echocardiography, which typically shows:

LVEF <45%

LV dilation (though PPCM may be non-dilated)

Reduced global systolic function

Sometimes functional mitral/tricuspid regurgitation

Additional workup includes BNP/NT-proBNP, ECG, CXR, and investigations to exclude ischemic or valvular disease as clinically indicated.

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Management: Treating Two Lives at Once

Management follows standard heart failure therapy, but with adjustments depending on whether the patient is still pregnant.

Key components include:

Diuretics to relieve congestion

Beta-blockers

Vasodilators (hydralazine/nitrates in pregnancy; ACE inhibitors/ARBs postpartum)

Anticoagulation when EF is severely low or LV thrombus is present

Bromocriptine (in some protocols) to inhibit prolactin, especially in severe cases

Mechanical circulatory support in cardiogenic shock

Multidisciplinary care with cardiology + obstetrics

Breastfeeding decisions should be individualized depending on medications used and severity of disease.

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Prognosis and Long-Term Outlook

The good news:

Approximately 50–70% of women recover normal LV function within 6–12 months.

However:

Persistent LV dysfunction occurs in some

The risk of recurrence in future pregnancies is significant, especially if EF fails to normalize

Severe cases may progress to advanced heart failure requiring transplant or LVAD

The single strongest predictor of outcome is LVEF at diagnosis.

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Why Awareness Matters

PPCM remains a high-morbidity, high-mortality condition—despite being treatable—because it is often recognized late.

Early diagnosis, timely echocardiography, and proper heart failure therapy dramatically improve outcomes.

For clinicians, maintaining a high index of suspicion during late pregnancy and early postpartum can be lifesaving.