Heart failure in pregnancy - Peripartum cardiomyopathy - what is it?

Peripartum cardiomyopathy is also often referred to as congestive heart failure (heart failure) in the puerperium, as it can first appear in the last month before birth to 6 months after. It is a rare disease in women who have not had any cardiological problems. In Germany in particular, this form of heart failure occurs with a frequency of 1:1500-2000 pregnancies. Interestingly, there are large national differences; in Nigeria, for example, it occurs much more frequently with 1:100 pregnancies.

Pregnant and heart disease

Even though the disease is fortunately rare in Germany, pregnant women should recognize the symptoms of possible heart failure. The symptoms can occur either suddenly, with onset within a few hours, or gradually over weeks, or months, in relation to the due date.

Unfortunately, however, the diagnosis is often made late, as it can be difficult to distinguish it from the common but harmless pregnancy complaints. The symptoms of peripartum cardiomyopathy can include shortness of breath - even at rest, fatigue or reduced performance, palpitations, dry cough or leg edema.

Heart failure in pregnancy - key role of the breastfeeding hormone prolactin

The cause of heart failure has not been conclusively clarified. In addition to genetic factors, immunological and inflammatory (inflammatory) processes are also thought to be involved. Furthermore, the breastfeeding hormone prolactin, which stimulates milk production, seems to play a key role in the development of peripartum cardiomyopathy. This is because oxidative stress probably leads to cleavage of the lactation hormone into a proinflammatory and an antiangiogenic fragment. This leads to a disturbance of the endothelial function (inner lining of the vessels) and disturbances in the microcirculation. Consequently, the heart muscle cells, called cardiomyocytes, come to harm.

Although the underlying mechanisms have not yet been conclusively clarified, certain predisposing risk factors play an important role. These include, for example, twin pregnancies, very young or older pregnant women, gestational hypertension or preeclampsia, malnutrition and belonging to an African ethnic group. According to a recent study, having first-degree relatives (parents and siblings) with heart disease, such as coronary heart disease or hypertension, also appears to be a significant risk factor.

Diagnosis by heart ultrasound

Die Diagnose sichern wir mittels Herzultraschall. Oft sieht man in diesem eine Einschränkung der systolischen Pumpfunktion von <45% (normale Pumpfunktion >55%). Die Erweiterung der linken Hauptkammer ist bei dieser Form der Herzschwäche nicht immer vorhanden.

Heart failure during pregnancy - what to do?

The therapy consists of a timely weaning. On the one hand, this means that prolactin (see above key role) is no longer produced, and on the other hand, the necessary therapy with cardiac drugs, some of which may not be given during pregnancy and breastfeeding, can also take place. This is because ACE inhibitors, AT blockers and spironolactone are actually strictly contraindicated before birth.

Ein neuer Therapieansatz besteht in der Gabe von Bromocriptin. Dabei handelt es sich um einen Dopaminagonisten, welcher die Prolaktin-Ausschüttung hemmt und damit auch die Entstehung dessen toxischer Spaltprodukte. Außerdem käme bei hochgradig reduzierter systolischer LV-Funktion, das heißt, wenn die Ejektionsfraktion bei <35% liegt, auch der Einsatz eines tragbaren Kardioverters/ Defibrillator (WCD) in Betracht. Dabei wird die Pumpfunktion mittels Echokardiografie im Verlauf kontrolliert. Desweiteren ist auch eine Thromboseprophylaxe notwendig, da ein erhöhtes Risiko für kardioembolische Ereignisse besteht.

Early diagnosis and start of therapy important

In conclusion, early diagnosis and initiation of therapy are critical for prognosis. Fortunately, since this usually happens in Germany, we often see complete recovery of systolic cardiac function and severe courses with heart transplantation or fatal outcome are rare (2%). However, an unfavorable prognosis exists when LV systolic function is highly compromised. Or in other words, when systolic pump function is less than 30% and enlargement of the left and right main chambers - also occurs.

Due to the high risk of recurrence of 30%, experts advise every affected woman against further pregnancy, even if cardiac function recovers. In pregnant women with corresponding risk factors, such as affected first-degree relatives with heart disease, cardiological monitoring would be particularly important.

• Arany Z, Elkayam U. Peripartum cardiomyopathy. Circulation 133 (14): 1397-1409
• Hilfiker-Kleiner D et al. Bromocriptine for the treatment of peripartum cardiomyopathy: a multicenter randomized study. Eur Heart J 2017, 38 (35): 2671-2679.
• Christiansen MN et al. Prevalence of heart failure and other risk factors among first-degree relatives of women with peripartum cardiomyopathy. Heart 2019; 105: 1057-62

 Cardiopraxis - Cardiologists in Düsseldorf & Meerbusch