Management of Pregnancy after Peripartum Cardiomyopathy

Background: Peripartum cardiomyopathy (PPCM) is a condition in which maternal heart failure develops in the last month of pregnancy, delivery, or up to 5 months postpartum. While the pathophysiology of the disease is still unclear, it is hypothesized to be multifactorial. Complications to the fetus include an increased risk for heart conditions, growth restriction, and intrauterine demise. Maternal complications include cardiogenic shock, acute respiratory distress, and long-term heart failure after pregnancy. Improvement of cardiac function after PPCM can happen up to 5 years after diagnosis. Patients are advised to avoid pregnancy with continued reduced ejection fraction or wait at least 5 years after their ejection fraction (EF) has stabilized. Case Description: This is the case of a 27-year-old G1P1 who presented 3 weeks after a cesarean delivery with worsening dyspnea initially diagnosed as pneumonia. Despite treatment, her dyspnea persisted leading to a work-up indicating PPCM with an ejection fraction (EF) of 20%. She was stabilized and started on metoprolol and empagliflozin. A year later, her EF improved to 48%. Her EF stabilized for a year but subsequently declined to 36% the year after. Return to baseline cardiac function occurred 6 years after her initial diagnosis when her EF reached 50%. Later that year, she became pregnant again. At the start of pregnancy, she was asymptomatic but her EF decreased to 40%. Empagliflozin was discontinued when she became pregnant and the metoprolol dose was decreased. Her EF returned to 50% a month later and she remained asymptomatic. After consultation with high-risk obstetrics and cardiology, she was started on hydralazine and isosorbide mononitrate with continued monitoring of her EF. This case report will discuss the patient’s disease progression and pregnancy management in the setting of heart failure with recovered ejection fraction after PPCM. This patient’s management involves the use of heart failure therapy, serial echocardiograms, and ultrasound, and utilizing a multidisciplinary approach between obstetrics and cardiology. The patient remains pregnant and continues to be followed. PPCM in subsequent pregnancies is not well studied, but cardiac complications frequently re-emerge in the peripartum and postpartum period. This case report discusses PPCM in a second pregnancy to gain a better understanding of the disease process and management. Many patients desire pregnancy after PPCM and understanding the management and implications of this is crucial.