Incidence and outcome of peripartum cardiomyopathy in a tertiary
care hospital
Year : 2019 | Volume : 7 | Issue : 2 Page : 18-21
Spandana K1, Ravinder Reddy Kasturi2, Mudgalkar N3, Srinivas Kumar A4, Vivekanada A5
1. senior Resident, Department of Medicine
2. Consultant cardiologist and Head of Department of Medicine
3. Consultant Cardiac Anesthesiologist
4. Consultant cardiologist, Director and Chief of cardiac sciences, Apollo Hospital, Hyderabad
5. Head of obstetrics and gynecology, Dean Prathima Hospital,Karimnagar
Address for correspondence: Department of Medicine, Prathima Institute of Medical Sciences,Nagnur road,Karimnagar.
Abstract
Aims and Objectives: To study the incidence, assess the risk factors and study
the clinical profile of patients with peripartum cardiomyopathy
and the outcome of peripartum cardiomyopathy.
Methods :
A prospective study and retrospective study of PPCM
was conducted at Prathima Institute of Medical Sciences,
Karimnagar, Telangana, India over a period of 4 years.
Prospective data was collected during the period of January,
2017 to October, 2018. Retrospective data was collected from
hospital records from January, 2015 to December, 2016. A total
of 92 patients were identified during the study period that
fulfilled the inclusion criteria.
Results:Overall incidence of PPCM in our institution
was 9 per 1000 deliveries. Patient age range was between 20
and 35 years. Mean age was 26 ± 4 years. Out of 92 cases, 40
cases were in the age group of 20-25yrs, 32 in 25-30yrs and 20
in 30-35yrs age group. 72 patients were of =30years of age
and 20 were of advanced maternal age (>30 years). 70 cases
were primiparous (76.08%) and 22 were multiparous (23.91%).
Two patients had twin foetuses. 37 patients (40.21%) developed
PPCM during pregnancy and 55 patients (59.78%) during
postpartum period. There were 12 (13.04%) maternal deaths.
All the 12 cases were aged less than 30 years and had severe
LV dysfunction.
Conclusion:Incidence of PPCM is not uncommon in
southern India. The incidence was 9 per 1000 deliveries in the
study. PPCM is not the disease of advanced maternal age and
multiparity as majority of the cases in the study were of age
<30years and primiparous.
Keywords :: peripartum cardiomyopathy,risk
factors,outcome.
INTRODUCTION:
Peripartum cardiomyopathy is a potentially lifethreatening
form of heart failure affecting women late in
pregnancy or in the early puerperium. There is no single
explanation of the pathogenesis. It is a diagnosis of exclusion.
A high index of suspicion is required for the diagnosis, as
shortness of breath and pedal oedema are common in the
peripartum period. PPCM is associated with a high morbidity
and mortality, but also with the possibility of full recovery. The
precise incidence in India is not known, an incidence of one
case per 1374 live births has been reported from a tertiary
care hospital from South India.1 This study aims to determine
the incidence and prognosis of PPCM.
PATIENTS AND METHODS :A prospective study and retrospective study of PPCM
was conducted at Prathima Institute of Medical Sciences,
Karimnagar, Telangana, India over a period of 4 years.
Prospective data was collected during the period of January,
2017 to October, 2018. Retrospective data was collected from
hospital records from January, 2015 to December, 2016. A total
of 67 patients were identified during the study period that
fulfilled the inclusion criteria. Inclusion criteria were Patients
with any parity and age, who are in their peripartum
period i.e. One month before delivery or within five months
of delivery, Patients presenting with signs and symptoms of
heart failure, Documented systolic dysfunction with
echocardiographic finding of Ejection fraction of <45% and
or Fractional shortening <30% absence of another identifiable
cause for the HF. Exclusion criteria were patients with preexisting
cardiomyopathy, pre-existing acquired or congenital
valvular heart disease, pre-existing undetected congenital heart
disease, diastolic heart failure due to hypertensive heart
disease, myocardial infarction secondary to coronary artery
dissection, coronary artery disease, coronary embolus/
thrombosis, and coronary artery spasm, pulmonary embolism
/ amniotic fluid embolism, COPD, severe anemia (hemoglobin
less than 10 g/dl), pulmonary artery hypertension, thyroid
disorders, septicaemia and patients with normal
echocardiography.
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Mortality rate was higher among the patients with
severe LV dysfunction, while most of the survivors had mild to
moderate LV dysfunction which was statistically significant
(p<0.005)
In the present study, 12 had pre-eclampsia (13%) and 2
had eclampsia (2.17%). Historically, many PPCM studies
purposefully excluded women with Pre-eclampsia or eclampsia
to avoid misclassification of Pre-Eclampsia -associated
pulmonary oedema as PPCM (the study by Vinay et al.1). It is
important to appreciate that Pre-eclampsia associated
pulmonary edema is a distinct clinical entity that occurs in the
presence of high blood pressure and increased cardiac
afterload, but unlike PPCM, it occurs despite a normal ejection
fraction. Bello et al8 recommended that women with Pre-
Eclampsia not be excluded from future studies of PPCM, in
light of their strong association. In a study by Bello et al.
, which was a systematic review and meta-analysis, the
prevalence of Pree clampsia in PPCM was more than 4 times
the average global rate expected in the general population
In the present study, all cases were discharged on oral
beta blockers, diuretics and ACE inhibitors. During the followup,
the drugs were sequentially withdrawn (diuretics, ACE
inhibitors followed by beta-blockers) depending on the LV
function recovery and symptoms.
Two patients had Torsade’s de pointes in the present
study. Both patients presented at during postpartum period.
One of the patients was on mechanical ventilator support and
had recurrent non-sustained polymorphic VT. She was
defibrillated twice and was started on amiodarone infusion
but the patient did not survive. The other patient was
defibrillated once with return of spontaneous circulation and
was started on amiodarone.
In the present study, three (4.4%) developed
thromboembolic events. Two cases developed CVA and one
developed cerebral sinus venous thrombosis. These three cases
had severe LV dysfunction. All the patients with an evidence
of LV thrombus on echocardiography were treated with Low
molecular weight heparin.
In the present study, there were 12 (13.04%) maternal
deaths.9 patients were primiparous and three was multiparous.
All the 12 cases were aged less than 30 years and had severe
LV dysfunction. Mean age of the deceased patients was 25.17
± 2.23 years. Mean LV Ejection Fraction (EF) among the
deceased patients was 26.67 ± 4.08 %. And the mean LV
Ejection Fraction (EF) among the survivors was 30.61± 6.12 %.
Although data regarding the risks of subsequent
pregnancy in women with PPCM remains incomplete, the
available data reported above indicate that PPCM patients are
at increased risk for worsening heart failure and death during
subsequent pregnancy. Patients who may be at highest risk
that is, those whose LVEF was <25% at diagnosis or whose LVEF
has not normalised should be strongly advised to avoid
subsequent pregnancy. In the present study, during follow-up one case was found to have uneventful subsequent pregnancy
without recurrence of PPCM. She had moderate LV dysfunction
at the time of presentation during first pregnancy and had
complete recovery of LV function at the end of 3 months.
CONCLUSION
To conclude, PPCM is not uncommon in India. It is a
diagnosis of exclusion. The incidence was 9 per 1000 deliveries
in the study. Present study defies that PPCM is the disease of
advanced maternal age and multiparty as majority of the cases
in the study were of age <30years and primiparous.There is no
single explanation for the pathogenesis of PPCM that is relevant
for all women. Early diagnosis and treatment lead to good
maternal and foetal outcome.
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How to cite this article : Spandana K, Kasturi RR, Mudgalkar
N, Srinivas Kumar A, Vivekanada A . Incidence and outcome
of peripartum cardiomyopathy in a tertiary care hospital.
Perspectives in Medical Research 2019; 7(2):18-21
Sources of Support: Nil,Conflict of interest:None declared