Outcome of subsequent pregnancy after peripartum cardiomyopathy from a low middle income country- a prospective single center study
Authors: Justin Paul G , Anne Princy S , Cecily Mary Majella J , Ravindran R , Anju Surendran S 
Published: October 2021

Abstract

Background
Heart failure is the most common complication of women wiht heart disease going through pregnancy. Peripartum cardiomyopathy (PPCMP) is the most common cause of heart failure in pregnancy. PPCMP presents towards the end of pregnancy or in the early months following delivery and has devastating medical, mental and socio-cultural consequences. PPCMP patients may land up with a subsequent pregnancy (SSP) due to cultural and social pressures. Early detection and management with multi-disciplinary approach is crucial.

Purpose
Analysis of clinical course, maternal and fetal outcomes in women with SSP after PPCMP in the index pregnancy (IP).

Methods
Women diagnosed with PPCMP between 2016 to 2019 in a tertiary referral centre in a low and middle income country, who had at least one SSP were included in this prospective analysis. Patients were followed up throughout the pregnancy and for two years after the SSP. Clinical presentation, medication use, echocardiographic data, breast feeding, contraception use, counselling given, maternal and fetal outcome of pregnancy were analyzed.

Results
Fifty-two patients were diagnosed to have PPCMP in our institution from 2016 to 2019. Seven patients had eight singleton SSPS. The mean age of these patients was 25.8±4.2 years.
Index pregnancy details: Five patients had required inotropic support during the IP with two of them requiring ventilatory support. Other two had mild heart failure. Eight index pregnancies resulted in five live births, one neonatal birth, one still birth and one medical termination of pregnancy (MTP). All five women with live births breast fed their children after the IP. Contraception by IUCD was used in four patients. Two women did not accept any means of contraception. All patients had underwent appropriate multidisciplinary counselling about risks of SSP. All except one patient had recovered LV function with LVEF ≥55% within one year of IP. Three patients had stopped anti failure therapy on their own before SSP. The mean duration of anti-failure therapy was 13±5 months.
Subsequent pregnancy details: (Fig. 1) One patient with non-recovered LV function developed HF during the SSP and underwent MTP at 20 weeks. She continues to have LV dysfunction and NYHA III heart failure. Six patients who had recovered LV function, did not suffer any recurrence, one of whom is still in the 34th week of gestation. One of these patients had two SSPs. The first SSP was uneventful without recurrence. She is in the 34th week of her second SSP and is uneventful so far.
Neonatal outcome of the SSPs was good with five live births and one MTP in the 6 completed SSPs.

Conclusion
Baseline LVEF after IP is an important predictor of maternal & fetal outcome outcome. With detailed cardiac evaluation including stress echocardiogram, multidisciplinary counseling and close supervision patients with previous PPCMP patient can be allowed for an SSP with reasonable safety.

Funding Acknowledgement
Type of funding sources: None. Figure 1. Flowchart of SSP outcome in PPCMP