Management of pregnancy in a woman with previous cardiomyopathy (Cardiomyopathy of pregnancy )

Cardiomyopathy of pregnancy in literal terms is development of heart failure either during pregnancy or following delivery.

·         Find out when she developed PPCM? (Antenatally or postnatally)

·         Was her previous pregnancy complicated by hypertension/PET?

·         Is she 40+ years old?

·         Is she Afro-Caribbean descent?

·         Also find out how much was her ejection fraction on cardiac echo?

Things to check at each antenatal visit:

·         Maternal pulse

·          respiratory rate,

·         pulse oxymetry,

·         Urine for proteinuria

Things to ask at each antenatal visit

·         Any breathing difficulty (h/o breathlessness, SOB)

·         Any h/o becoming breathless for routine tasks  (Reduced physical capacity)

·         Rule out palpitations

·         Ask any swelling of limbs, face and back

Diagnostic criteria for PPCM

·         Echo is a must to diagnose PPCM

·         Left ventricular ejection fraction <45 p="">

·         Fractional shortening by 30%

·         Enlargement of heart  and global dilation of all four chambers and markedly Lt.ventricular function

Management of pregnancy

·         If develops antenatally, if baby viable and closer to term, consider elective delivery

·         Thromboprophylaxis once there is impaired left ventricular dysfunction or arrhythmia

·         Closely liaise with Cardiologist

·         ? Three monthly cardiac echo and monthly ECG or earlier if she becomes symptomatic.

·         Holter monitoring

·         FBC, U/Es, LFTs

Intrapartum and postpartum management

-          Consider intervening the pregnancy, only if she becomes symptomatic and echo proves PPCM

-          Avoid prolongation of second stage

-          Avoid ergometrine/methylergometrine. This is because following delivery, there is immediate rise in cardiac output due to the pressure off from inferior vena cava. Cardiac output increases by 70% followed by rapid decline to prelabour levels within one hour of delivery.

-          Avoid excessive intravenous fluids.

-          Consider giving Syntocinon by syringe driver rather than by syntocinon infusion.

-          Encourage early ambulation.