The Hidden Phase: Recognizing Late-Onset Peripartum Cardiomyopathy in Ethnic Sub-Saharan African Populations

Background: Peripartum cardiomyopathy (PPCM) is a, life-threatening heart muscle disease affecting women during late pregnancy and postpartum. Traditionally, PPCM diagnosis has been limited to symptom onset within 5 months after childbirth. However, this long-established timeframe is debated as potentially too restrictive, and detailed reports on late-onset PPCM, are scarce. Methods: This prospective study in Sokoto, Nigeria, consecutively recruited 10 patients over 48 months who presented with heart failure symptoms beyond the conventional 5-month postpartum diagnostic timeframe (window) but still met the European Society of Cardiology (ESC) diagnostic criteria for PPCM. Results: The cohort comprised predominantly young women (90%), mean age 30.5 ± 6.5 years), most of whom were multiparous (80%), well-educated (90%), of middle socioeconomic status (80%), and unemployed (100%). All had adequate antenatal care, hospital delivery, and were actively breastfeeding at symptom onset. The mean duration from delivery to symptom onset was 13 ± 2.1 months and the mean duration of symptoms prior to hospital presentation was 3.2 ± 3.74 weeks. Patients typically presented with left-sided heart failure (80%) and in NYHA class II (70%). On auscultation mitral regurgitant murmur was detected in (50%). Echocardiography frequently showed 4-chamber dilatation (50%), mild to moderate LV systolic dysfunction (60% mild, 40% moderate). Left ventricular (LV) structural pathological remodelling (abnormal LV geometry (100%) and abnormal LV mass index (100%). and 4, 2 & 3 chamber dilation (100%). Significant mitral regurgitation was also common (50% moderate, 20% severe). Most common electrocardiographic findings included sinus tachycardia (100%) and prolonged QTc (70%) and T wave inversion (50%). All patients had cardiomegaly and cardiogenic pulmonary edema on chest X-ray. Conclusion: The findings from this small cohort in Nigeria highlight the clinical presentation and characteristics of late-onset PPCM occurring significantly beyond the traditional 5-month postpartum window. These data support the need for considering PPCM in women presenting with heart failure symptoms later in the postpartum period, even outside historically defined timeframes, provided they meet established ESC working diagnostic criteria.