Counseling Women with Peripartum Cardiomyopathy About Subsequent Pregnancies

Educational Objectives

After completing the activity, the clinician will be better able to manage patients with peripartum cardiomyopathy and counsel patients with a history of peripartum cardiomyopathy about their risks in subsequent pregnancies.

Summary

Counseling Women with Peripartum Cardiomyopathy About Subsequent Pregnancies

Correspondent: Purvi Parwani, MBBS, MPH, FACC; Loma Linda, CA

Take-home Messages:

• Peripartum cardiomyopathy is often overlooked and poorly understood. The prevalence is low (although it is likely underdiagnosed) and is estimated to be between 1 in 1000 to 4000 pregnancies.

• Echocardiography is used for diagnosis, although brain natriuretic peptide (BNP) may be useful as well.

• Left ventricular ejection fraction must be <40% to meet criteria for peripartum cardiomyopathy. It is considered a diagnosis of exclusion (other diagnoses causing heart failure [HF] should be absent).

• BNP may be mildly elevated during a normal pregnancy, and symptoms that occur during pregnancy and the early postpartum period may be similar to those of HF.

• A study from the University of Toronto (Tanous et al., 2010) showed that a BNP ≤100 pg/mL had a high negative predictive value for having an adverse maternal event.

• BNP can be a good initial screening tool, but echocardiography is necessary to confirm diagnosis of peripartum cardiomyopathy.

• An increasing number of postpartum women are developing shortness of breath, elevated BNP, and preserved systolic function on echocardiography, and this cohort should be studied further.

• Women may be instructed to avoid subsequent pregnancies by medical professionals, but this recommendation is complicated and nuanced.

• Rate of recovery, severity of HF, and degree of recovery affects the recommendations for future pregnancies.

• Patients who want to become pregnant after a history of peripartum cardiomyopathy should consult with a practitioner who has experience in caring for patients with a history of peripartum cardiomyopathy.

• Pregnancy is likely to be risky for women with advanced HF who need high levels of support, but other patients are in a “gray area,” and factors such as whether heart function has fully recovered and the specific risks of a subsequent pregnancy requires further consultation.

• Patient support and social media groups can be helpful for patients to get connected with others who have personal experience with peripartum cardiomyopathy.

• Treatment for peripartum cardiomyopathy is similar to that for HF with reduced ejection fraction, although angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are contraindicated during pregnancy.

• When counseling patients about pregnancy, ACE inhibitors and ARBs are often discontinued, and ejection fraction is assessed to ensure that function of the heart has fully recovered.

• Bromocriptine was initially used as a lactation suppressant and has been used in peripartum cardiomyopathy. However, it has not been compared with placebo in a large multicenter randomized controlled trial and does not have general recommendations for use in current practice.

• In summary, the decision to have a subsequent pregnancy after prior peripartum cardiomyopathy depends on whether the heart has fully recovered.

• Transthoracic echocardiography is generally used for assessment, and many studies define recovery as an ejection fraction of ≥50%.

• Additional testing modalities currently being explored include strain imaging and exercise testing, which involve stressing the heart to see if function remains normal.

• Some women may have subclinical cardiac dysfunction that is not detected on general surface echocardiography.

• Assessment of the ejection fraction is important for predicting risk for relapse during pregnancy, recurrent symptoms, and decrease in ejection fraction, as well as risk to the fetus.

References

1. Joseph M and Davis MB. Counseling women with peripartum cardiomyopathy about subsequent pregnancies. Current treatment options in cardiovascular medicine. 23. 10.1007/s11936-021-00915-4.

2. Davis MB, Arany Z, McNamara DM, Goland S, Elkayam U. Peripartum cardiomyopathy: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75(2):207-221. doi:10.1016/j.jacc.2019.11.014

3. Tanous D, Siu SC, Mason J, et al. B-type natriuretic peptide in pregnant women with heart disease. J Am Coll Cardiol. 2010;56(15):1247-1253. doi:10.1016/j.jacc.2010.02.076

Readings

Disclosures

Melinda B. Davis: This author has nothing to disclose.

C. Noel Bairey Merz: Consultant Fees/Honoraria: Med Intelligence (Caladrius lecture); Other: Bayer (Advisory Board), iRhythm; Research/Research Grants: California Institute for Precision Medicine, DoD Warrior, NIH-NIA Grant (SCORE), Sanofi-Aventis, WISE pre-HFpEF.

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

AC531209

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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