Considering Post-PPCM Pregnancy?
What can a PPCM survivor do to reduce the risks of relapse heart failure in a subsequent pregnancy?
Last Reviewed: 12/01/2017
A) Before the post-PPCM pregnancy:
1. Adequate treatment of first episode to help reach left ventricular ejection fraction (LVEF) of 55 % (anything higher considered a “variant of normal”).
2. Be sure that “contractile reserve” is adequate; defined as increase of LVEF by at least 15 % from resting heart rate to target exercise heart rate on exercise stress echocardiogram (example: from LVEF 55 % to 63 %).
3. Maintain normal heart function (LVEF 55 %) after phase-out of medication that would not be safe during conception/pregnancy; such as ACE-Inhibitor or ARB (angiotensin receptor blocker).
4. ”Full recovery” confers lower risk, and means
a) No diastolic dysfunction; if that exists more Rx indicated.
b) No LGE (late Gadolinium enhancement) on cardiac MRI.
c) Size of left ventricle < 6 cm or < 3.5 cm/M2 BSA.
B) During the post-PPCM pregnancy:
1. Establish base-line serum BNP (B-type Natriuretic Peptide) and monitor serum BNP level each trimester. Look for levels that are rising and/or above “cut-off” level for your lab’s test. The NT-ProBNP test is recommended because it appears to be the least affected by pregnancy alone.
2. Monitor LVEF by echocardiography each trimester and more often if serum BNP is rising and/or above “cut-off” value.
3. Rising serum BNP above “cut-off” is an indication to consider starting a treatment (first choice: beta-blocker) because that comes before any fall in LVEF.
4. Monitor the “self-test” monthly for recognition of signs and symptoms of heart failure during pregnancy.
5. Watch for further developments of this research tool:
--serum soluble FLT1 >100 pg/ml
--ratio of sFLT1 to Placenta Growth Factor (PlGF) > 50 @ 24 weeks gestation. This may be predictive of trouble @ 32 weeks gestation.
10 keys to a successful post-ppcm pregnancy
Author: James D. Fett, MD | Last reviewed: 3/30/2018
1. Strongly advised to only seek post-PPCM pregnancy if willing to risk the possibility of relapse of heart failure and ideally be recovered to LVEF 55%. There is higher risk for relapse of heart failure if LVEF less.
2. Be sure ACE-Inhibitor (ACEI) or angiotensin releasing hormone blocker (ARB) medications are no longer needed and have been stopped: too much danger to fetus.
3. Rising ratio of serum solubleFLT-1 to Placental Growth Factor is adverse prognostic sign for preeclampsia, pregnancy-induced hypertension and PPCM. Warning if over 30 @ 10 weeks; over 80 @ 30 weeks.
4. Be sure to monitor blood BNP during pregnancy, including the last month of pregnancy: a rising level above lab’s “cut-off” may be seen hours to days before clinical symptoms of heart failure.
5. Be sure to do periodic “quick-look” echocardiograms for LVEF, including the last month of pregnancy: slippage of LVEF may appear ahead of any clinical symptoms.
6. Frequently review “self-test”*** for recognition of heart failure during pregnancy: a score of 5 or more may be seen days to weeks ahead of significant (> 5 points) decrease in LVEF.
7. Alert your OB Team, which includes nurses and perinatologist, to all of the above so they are in tune with the risks.
8. Confirm suspected relapse by “quick-look” echocardiogram for LVEF if any of the above suggests relapse is occurring.
9. Start treatment immediately if relapse is confirmed: this includes tolerable dosages of a beta-blocker (BB), metoprolol succinate or carvedilol; and is often helped by the use of hydralazine, with or without nitrates, depending upon the blood pressure and heart rate. The hydralazine could/should be replaced by ACEI or ARB after delivery.
10. With relapse, and when stabilized by treatment, work with OB to complete delivery when safe for the newborn. Safe delivery is the best way to promote the recovery process, including return of immune system to normal.
**There can never be any guarantees, and there is always a possibility for relapse of heart failure. One must be prepared to identify/deal with relapse.
+1*: I also recommend consideration of exercise stress echo and exercise peak cardiac output/02 consumption to assess contractile reserve. Assessment of contractile reserve may help to determine ability of heart to tolerate the stresses of pregnancy and delivery. Contractile reserve should be at least 10 to 15 %.
** Fett JD. Personal Commentary: Monitoring subsequent pregnancy in recovered peripartum cardiomyopathy mothers. Crit Pathw Cardiol 2010;9:1-3.
** Fett JD, Fristoe KL, Welsh SN. Risk of heart failure relapse in subsequent pregnancy among peripartum cardiomyopathy mothers. Int J Gynecol Obstet 2010;109:34-6.
*** Fett JD. Validation of a self-test for early diagnosis of heart failure in peripartum cardiomyopathy. Crit Pathw Cardiol 2011;10 (Mar):44-45.
****Fett JD, Shah T, McNamara DM. Why do some recovered peripartum cardiomyopathy mothers experience heart failure with a subsequent pregnancy? Current Treatment Options in CV Med 2015 Jan;17(1):354.