← Dr. Chapa’s OBGYN Clinical Pearls 
Dr. Chapa’s OBGYN Clinical Pearls
Peripartum Cardiomyopathy (PPCM): When the Left Heart Falters
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See what I did there? Into the heart of ob, gyn, physicians, midwives, MFM providers, and of course, even cardiologists. This is peripartum cardiomyopathy. Look, heart issues in pregnancy has gotten so bad that there's now a subspecialty called cardio obstetrics. Man, that's creepy, isn't it? Peripartum cardiomyopathy. If you're an attending, especially if you're just graduating, coming up here at the end of June 2026. Because that's when we're recording this, in the month of June, getting ready to start your private practice or a new attending job. Keep your eyes open for peripartum cardiomyopathy. It is scary and it does people in. So we gotta be aware of prevalence, symptomatology, the workup, prognosis, and of course, counseling after the fact. So we're gonna talk about all these things. This comes from one of our podcasts, family members who said, hey, you know, we ran into this issue of peripartum cardiomyopathy and there was some confusion because of course she was preeclampsia with severe, which is one of the risk factors. And so we got distracted by the mag thinking she was mag toxic. In fact, she had peripartum cardiomyopathy and they were late in getting the echo. So we're gonna talk about this because preeclampsia with severe features is a risk factor for ppcm. Peripartum cardiomyopathy. Honestly, guys, this is horrifying I've had my own share of cases that I've worked on and you gotta jump on this fast. Peripartum cardiomyopathy is no joke. So, podcast peeps, that's where we're going. We're gonna talk about the union and the intersection of obstetrics, maternal fetal medicine and cardiology. We're gonna talk about peripartum cardiomyop. All right, I think I've set it up enough. We will be right back. We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OBGYN no Spin podcast. Yeah, nobody can even try to fake it. Everybody gets afraid of. And we should have a healthy fear, a healthy respect for peripartum cardiomyopathy. I don't care if you're a fellow, if you are an attending, if you're an obgyn hospitalist. This thing is just scary. Usually presents pretty quick. Shortness of breath, maybe some palpitations, some chest pain. And your brain should go to peripartum cardiomyopathy, especially in the right side setting, which I'm about to tell you. So, yeah, this is something legit to be aware of. And it's the leading cause, of course, of peripartum morbidity and mortality. And it seems to be getting worse as hypertensive disorders in pregnancy increase, as multiple pregnancies, multiple gestations increase because of ivf, older patients. We're going to talk about risk factors here in a minute, but before we do all that, remember we're talking about peripartum cardiomyopathy, which is a very distinct type of left ventricular heart failure. So remember, left ventricle, it's the outside pump pumping outside to the system. That's a problem. Which means everything downwind of that, everything upstream, so to speak, I guess, gets backed up. Okay. That's why you get pulmonary edema. This is different than right heart failure. This, that can be caused by things like pulmonary hypertension or a big pe. Those are different. This is left sided heart failure that mimics dilated cardiomyopathy. Trust me, we're going to work through, go through the work up here very quickly. Rapid fire. I'm going to tell you about some of the medications that can be used. Of course, the diagnostic test, the labs, and how to get this thing under the control. Now, first of all, let's take a look at the numbers. Thankfully, it is one of those things that is rare. That's the good news. The problem is, is that it's pretty bad when it happens. The numbers are kind of all over the board. Anywhere from one in a thousand to one in four thousand life births. Even though there is some global and geographic differences, this thing strikes. Here it is, guys, primarily in the last month of pregnancy and within the first six months following delivery. So this is kind of time for peripartum, hence the name peripartum cardiomyopathy, within the last month of pregnancy. So 36 weeks onward up to really about the first six months post delivery. And who's at risk? Well, the data show that there's a significantly higher prevalence in patients of African descent, women over the age of 30, multifetal gestation, and of course those with a history of past peripartum cardiomyopathy and or current severe hypertensive disorders in pregnancy and including preeclampsia. All right, so these are issues here. So things to keep in mind. Multiple gestation, any kind of hypertensive disorder, especially if it's on the severe range because you're going to have most of the afterload issue there stressing the heart, women over the age of 30. All right, so here's a big clinical pearl. That tie to preeclampsia brings us directly to one of the proposed etiologies. Now, remember, we used to historically say, oh, it's idiopathic, I don't know, it could be viral. There's a component of genetic, there's a component of oxidative stress. When. Now some of the newer data says that peripartum cardiomyopathy, PPCM is most likely a two hit phenomenon. Now this is a theory. I'm not saying that I have discovered the cause of peripartum cardiomyopathy, but it is one of the leading theories. All right, the first hit seems to be a late pregnancy antiangiogenic stress where the placenta starts to secrete more high levels of soluble FMS like tyrosine kinase 1 that impairs blood vessel health. That's the same one that's involved with soluble FMS, lityrosine kinase 1 and placental growth factor, the same ratio that the thermo Fisher test checks for, that we've covered in the past. All right, so remember that unlike placental growth factor, the cause of vasodilation, and it's soluble FMS like tyrosine kinase 1, that's the little S FLT1, that biomarker that's secreted by the placenta and by the spiral arteries junction that leads to this extra Stress on the blood vessels, where then kicks back to the heart, and the heart's like, oh, great, here I go. Now, that's the first hit. The second hit has to do. Remember, as pregnancy advances. This is interesting, and again, not widely accepted by all, but there is a relationship to prolactin. That's right, the breastfeeding hormone. We can get into breastfeeding in a minute, because I'm not gonna throw breastfeeding under the bus, but there is a component where prolactin gets cleaved in a weird way. And then that cleavage molecule, it's actually called the 16kDa protein fragment. That. That prolactin fragment can cause specific toxic results to endothelial cells, cause microvascular damage, and then that leads to subsequent left ventricular dysfunction. What? So the two things is possibly related to soluble FMS, Lightros and Kinase 1. That's the first hit. That kind of sets the stage. And then as prolactin starts to, you know, kind of rev up, it gets cleaved in a weird way. And this may be a genetic tie. I'll tell you the genetics of this in just a minute. That causes increased oxidative stress and vasoconstriction that then talk back to the heart and go nuts. And. Okay, so that's the two hit process. Now, because we said prolactin, I got to talk everybody off the fence here, because then prolactin breastfeeding, is that okay? Yes. In general, the US Says breastfeeding has much more advantages than the metabolic demands and the theoretical risks that that places on the heart. So knock yourself out. But. But not everybody agrees, okay? There is the European Society of Cardiology. Just last year, guys, 2025, there was a good review of this published in the Lancet that says, yeah, in general, breastfeeding is fine. Don't worry about the prolactin issue. I get that. It's fine. That's a different mechanism. And lactation should be okay. Unless, remember, this is Europe, okay? European Society of Cardiology, not the US Unless they have severe cardiogenic shock. And if you got cardiogenic shock, man, you got other things to worry about, honestly, than breastfeeding. So I get that. So if your left ventricular ejection fraction is less than 25%, which is pretty damn low. I'll tell you what the diagnostic cutoff is for PPCM here in just a minute. But if your ejection fraction from the left ventricle is less than 25%, basically you're in cardiogenic shock, you got other things to worry about than giving yourself extra stress to the body, like lactating. So maybe in those women, maybe it's not so good of a thing. So that is a caveat where they say, you may consider. It's not even a restriction. It's, you may consider not letting those with severe cardiogenic shock breastfeed. Okay? Now, because we're talking about prolactin and breastfeeding, you should be thinking, hmm, I wonder. Choppa. I wonder if prolactin and bromocriptine. If bromocriptine would have a role here. Ah, that is in SMFM's console series 73. Short answer is no. There is some studies. I'm gonna read it directly out of the console series that show promise. But bromocriptine right now for heart failure is not standard. It's still considered experimental. Animal studies and limited human trials have suggested that bromocriptine may benefit left ventricular recovery in peripartum cardiomyopathy. Why? Because of that prolactin and abnormal fragmentation. All right? However, listen to this, guys. This has not been confirmed in larger trials. Now, they go on to say bromocriptine is recommended as an addition to. To standard therapy for PPCM in Europe, although it is not currently approved by the US FDA and does not carry that indication or approved use in the United States. End quote. So just to be clear, Europe does have some changes. They do do things a little bit differently. No problem. No one's mad at them. But right now in the US if your cardiologist says, should we give her bromocriptine, go. I know those studies. It's definitely not going to hurt. But as of right now, it's not considered standard of care in the United States. We're going to stick with the traditional. And I'll give you what those traditional medications are here in just a minute. All right? So bromocriptine and prolactin, interesting stuff, right? Now, this prolactin tie in, and the vasospasmic response is tied to some genetic loci. We know that. All right? Specifically the MYH genes. Myh. That's myh. That family, specifically number seven and number six seem to carry the genetic part of the puzzle there, along with ttn. Those are the genes with mutations in those genes that have been linked to peripartum cardiomyopathy. So this whole thing of. Well, it's likely idiopathic. No, no, no. There's a genetic tie. There's a tie to angiogenic vasospastic stress. There's a tie to abnormal cleavage of prolactin antisoluble, like tyrosine kinase 1 buildup. All right, so we do know. So the chunk that is idiopathic is kind of cleaving down. Okay? So very quickly, guys, remember that we're talking about the left heart failing, which means that everything prior to that, meaning the lungs get backed up as well as backflow. So you get edema and you get pulmonary edema, which are the big issues. All right, now we're going to talk about presentation. First, we'll talk about differentials, and then I'm going to give you the workup if you can't figure this out already. The workup is pretty straightforward, as you would think for ruling out anything cardiac. And this is exactly what SMFM says. Guys, pay attention to this. We can't just go straight to peripartal cardiomyopathy. We got to look for other things. Is this tyrotoxicosis? Is this a pe. Is she having an mi? An acute cardiac event. We got to think about those things. And then once we rule those out. Quickly, quickly. Then PPCM comes into place, and you can do all of these differentials in parallel. As you're ordering the test, go boom. Her ejection fraction is less than 45% percent. That's. I'm hanging my hat on. That is cardiomyopathy. Okay? So I'm going to tell you that specifically here. These cutoffs and diagnostics in a minute. But in general, the presentation. And here's where it gets dangerous. The presentation can kind of look like some normal changes of pregnancy. There's mild shortness of breath. Hello. There is some pedal edema, which pregnant woman doesn't have that. There's fatigue. Yeah. So in mild cases, when a patient says, I can't catch my breath, you know, my feet are getting really swollen. Don't go, ah, honey, that's pregnancy. Yes, it is. You gotta listen to the lungs, and you gotta ask her, are you having functional limitations at rest? That's where the New York Heart association classifications come into play. And you gotta start risk stratifying her by that. What is never normal? What is never normal is orthopnea that's needing multiple pillows to sleep. If they have paroxysmal nocturnal dyspnea, they wake up at night because they. I mean, they just can't catch their breath. That's not normal. If they have bibasalar crackles, that's not normal. And if on exam, they've got JVD in their neck. You gotta start thinking, hey, maybe this is something more than just pregnancy. All right? So take a look at these things. Even a persistent dry cough, all right, that's not related to sinus congestion or, you know, runny eyes. A persistent dry cough, guys, is the body trying to clear the lungs out of stuff. So pay attention to these things. Basilar crackles if there's a dry cough. Jvd, for sure. All of these things happen when the left ventricle can't pump forward, so fluid backs up from that into the lungs. So that is your classic presentation, as you would think with anybody with heart failure. Now, the differential diagnosis here has to be broad. Think is this severe preeclampsia, preeclampsia with severe features with acute pulmonary edema. Remember, pulmonary edema is one of the severe criteria, so you gotta rule that out. Now, the way that you would figure that out, the only way to figure that out, if that's just a manifestation of severe preeclampsia or heart failure, is that echo. Because while the echo may show some left ventricular hypertrophy, with preeclampsia, the ejection fraction should be maintained. All right, think pulmonary embolism. Is this possibly an afe, especially after delivery or after a C section. Is this maybe some unmasked prior, you know, valvular disease? That's why you still need to get that echo. And if they're on MAG in the immediate postpartum interval, could this be MAG toxicity? As you should consider for any shortness of breath, Y' all got this. So think heart, think lungs, and then think larger environment, like mag. Okay, so we got to exclude other causes that straight out of the SMFM console, series 73, before we label this thing PPCM. As we're doing all of these evaluations and diagnostic tests, rapid fire, one after another. So remember, somebody who looks ill, weird shortness of breath, dry cough, and they got crackles. Move. You gotta move. Think pulse ox and chest X ray quickly. Because those are typically very fast to get along with an ekg. So the triad guys, the triad to get very quickly, boom, slap on a pulse ox, get a chest X ray and get an ekg. Now, an EKG is most likely to be abnormal. The issue is, is that the abnormalities are very nonspecific. You're gonna see the typical. You can see some signs of tachycardia. You're gonna have maybe some flat or some inverted T waves, some nonspecific ST segment changes, especially in the lateral or the inferior leads, okay? You're also gonna see some left ventricular strain. So if you see left ventricular strain, some funky ST waves and some flatter inverted T waves, and the chest X ray shows bilateral edema. Man, you gotta go. I need to bring me the echo. Cause I'm gonna do it myself. No, don't do it yourself. Get a trained technician. My point is you need a transthoracic echo quickly. So get a tte, a transthoracic echo, because that is how you're going to make the diagnosis. That is the gold standard. Now, everything. There's a caveat to everything. It is possible to have heart failure with a normal ejection fraction. But that's rare in general in the world of medicine. And it's not the kind of heart failure that you get with peripartum cardiomyopathy. So listen up very quickly. Transthoracic echo is the gold standard and you're going to see it with an ejection fraction at or under 45%. Some use 40%, some say 45%. Depends on who you read. But SMFM says you definitely have it at 40% and you most likely have it under 45%. So Echo is key. Echo is key. I'm going to tell you about the labs here in a minute. If your echo, for whatever reason says, man, you know, I just, I don't know, I'm getting an ejection fraction of like maybe 46. I don't know. Whatever. The point is this borderline and you just can't really tell. Then there is a role for Mr. Of the heart. There's a cardiac Mr. And you gotta tell the radiologist. And first of all, you gotta have a good technician and you have to have a good radiologist who's trained to look at cardiac misters, okay? Because there is a role, especially when the echo is non diagnostic, for a magnetic resonance scan of the heart to look for left ventricular structure, look for any valvular issues. You can look for wall motion. This is an important thing. And it also looks for dimensions, of course, of the great vessels. When you need to build up your team to handle the growing chaos at work, use Indeed Sponsored jobs. It gives your job post the boost it needs to be seen and helps reach people with the right skills, certifications, and more. So spend less time searching and more time actually interviewing candidates who check all your boxes. Listeners of this show will get a $75 sponsored job credit@ Indeed.com podcast. That's Indeed.com podcast terms and conditions apply. Need a hiring hero. This is a job for indeed sponsored jobs. Now I get it. CT is much easier. It's faster. Usually you don't have to call a tech in. Most people can do a CT scan very quickly. But. But cardiac, Mr. In weird cases is the preferred imaging modality when the echo is not conclusive. All right, so if somebody asks you, what's your diagnostic test of choice? Well, it's not my diagnostic test of choice. It is a test of gold standard. That's the echo with a second finisher. A second place maybe being a cardiac mri. Now, what about biomarkers? Yep, that's. That's where SSMFM Console Series 73 also gives us some guidance. BMP and NT Pro, BMP the fragment. Both of those are good. Even though they both rise in pregnancy to some degree, they shouldn't rise to be super abnormal. And the short answer, guys, is the higher they are, the really more abnormal the heart strain is. Both of these are a measure as a barometer, so to speak, of heart strain. So B type natural peptide or BMP values greater than 150. You know, start thinking a lot of strain here. And NT Pro, BMP, that's greater than 450 or 500. Both of those should get your attention. But podcast family, here's the catch, because nothing is simple, okay? You gotta interpret these things in the clinical context because both bnp, which tends to have a lower value than NT probnp, that one is typically, because it's a fragment, tends to be much higher in their numbers. Both of those can go up with a lot of conditions. Just having preeclampsia, guys, just having preeclampsia. That heart says, man, I don't like this pressure. And it's gonna be elevated, but not to the degree with PPCM. I mean, there's been values of like 800 to a thousand for NT Pro, BMP. All right, some people like the fragments, some like regular bmp, whatever. Do whatever your hospital does. Our hospital uses more of the NT the Pro fragment. And you can get levels. Yeah, like, like 1200. So the higher, if it's over a thousand for the fragment, you got to think something is wrong. Even pulmonary edema can throw off that value because of the right heart strain. Sepsis can also throw off your BMP and NT propion B, for obvious reasons. So there are other things that can cause those elevations. But it is still a useful test. SMFM says still a useful test. Get them because it's going to give you another Piece of the puzzle that helps build your diagnosis in addition to the echo. All right, all right. Now, talking about labs, we're going to talk about the labs that we're going to get here to be complete. Because remember, we got to look for other organic or non organic things like a mag level. I mean, it's not a structural issue, it's an environmental issue that puts a functional depressive effect on the heart. So we're going to talk about the labs here. But before I do, quick word about our sponsor. Remember that Tona Activewear is our sponsor. So with the link in our show notes, you can get 16 off anything on the website just because you are a member of the Choppa no spin podcast family. So find the link in our show notes, that is tonaactivewear.com. thank you, Tona, for believing in us and our Message for your 6 15% off anything on the website. Okay, now that we've done that, let's get into the labs. Cbc, cmp, get a blood gas. I know that sucks and it kind of hurts a little bit, but a blood gas is important, especially if she's decompensating fast. Get a TSH to rule out thyrotoxicosis. Get your troponins. You still need your troponin. Whether it's a general or a highly sensitive troponin, you got to get that to look for MI and then a tox screen if you feel that that is necessary. If you suspect sepsis, don't forget your lactic acid. I like lactic acid. I think it gives me an idea of what's going on. Even though normal labor can give you a bump in lactic acid, that clears with hydration, if you don't know what's going on, I pan lab these folks, all right? Because I don't want to miss anything until I get that echo. All right, now we've done all that. We're talking about presentation, we've talked about labs. Now one of the things that I want to get into here is management because. And then we're start wrapping this up. This is very easy, guys. The pump don't work, so we got to help the pump out. And the way that we're going to do that isn't with an implantable device, even though that has been a thing when they're very, very sick. We're talking about medications, right? So think meds, meds, meds, meds to fix this thing. And of course, this matters if she is pregnant or no longer pregnant, meaning postpartum, because that's gonna affect some of the medications that we give. Okay, but a big clinical pearl right off the bat is if they are in acute heart failure. Here it is, guys. Common sense prevails. Don't give her a beta blocker. Now why this is important is because remember, some of these patients have preeclampsia or hypertensive disorder of a pregnancy of some flavor. And we like our beta blogger. We like little beta law. But not in acute heart failure. You can do that once they've recovered as maintenance if they need to, but not during acute episode. That is an SMFM's consult series. Of course, any medicine and cardiologist will tell you, avoid beta blockers, avoid anything that is an anti contractile agent because that's gonna worsen the situation. Okay? At least in the acute hemodynamic instability phase. As you would think, this is a volume overload issue and a bad contractility issue. So we gotta fix those things. If still pregnant, then we gotta focus on volume optimization and getting that afterload reduction in place. So loop diuretics like Lasix. No problem. You can do that. It's better that she breathes than the fear of giving somebody Lasix. Go ahead and give Lasix. And for afterload reduction, SMFM likes hydralazine and nitrates. Those are always your safe to go because they work very quickly. So hydralazine and Lasix. Hydralazine and Lasix, that's the way to go. Now, if they're postpartum, you've got more options because there all of the options are full steam ahead. All of the meds are okay with breastfeeding. And so you want to definitely do afterload reduction with any of the usual agents. SMFM likes ACE inhibitors. You can do an arbitrary. An angiotensin receptor blocker. You can do an Arni. An Arni. You can do that immediately after delivery. Now remember, of course, you still need consultation education of the patient to let them know, look, these meds are okay right now because you're no longer pregnant. However, if you do want to get pregnant, then we got to switch you off these meds because you cannot get pregnant on these medications. So it's a good thing for patient education as we talk to them also about education anyway in terms of relapse, because this thing could be bad. But you gotta tell them, of course, that at the first thought of getting pregnant later, that you gotta stop those medications. All right? So ACE inhibitors, ARBs, RNAs and spironolactone are contraindicated during pregnancy. And Especially for those women trying to get pregnant because of issues with embryology. Now, we all get that. We get that. Take away fluid, help the heart contract, take away afterload. We get that. But here's where people forget in podcast family. This is going to be one of the last clinical pearls. I'm going to wrap this up, Lovenox. SMFM makes it very clear in those patients, guys who have acute left ventricular failure, especially if the ejection fraction is under 30. Remember, the diagnostic is under 45, some say under 40. But if you have an ejection fraction that is severe, under 30%, you're not moving any of that blood, okay? So that blood is just staying there, and that blood is going to clot, especially in the peripartum period. So SMFM says in the inpatient setting, prophylactic anticoagulation with heparin, or low molecular weight heparin is advised for patients with acute left ventricular failure. Now, that's for inpatient. That's where most of the data lies. What to do with them once they're discharged is a separate issue. Nobody really agrees with that. There's different opinions. I continue that for at least 10 days postpartum because that blood is not flowing well. Okay. But not everybody agrees with that. So definitely inpatient. I do 10 days, some do two weeks. But as SMFM says, quote, if outpatient prophylaxis is prescribed, the duration and the dosage should be determined with input from a multidisciplinary care team and with shared decision making. That is right out of consul series. Number 40. I'm sorry, number 40. Number 73. Podcast family. That was a lot. I mean, we covered peripartum cardiomyopathy not just at a high level, but the specifics, what to look for. Think about a differential. Remember, get that fluid off and take the afterload release, because that's going to help the heart contract. It's hard for the heart to contract if you got vessels that are super squeezed tight. The pump doesn't have that much pressure. So take away the afterload reduction with hydralazine or nitrates and get that volume off. Prognosis is directly tied to what that final ejection fraction looks like. It's obviously very good if it's above 40, and the prognosis is not great if it's under 30. But weird stuff happens. There have been some patients with very low ejection fractions that recover, but that is a very poor prognostic sign for spontaneous recovery. So when a patient asks first of all, is this going to happen again? Well, first, let's get you through this, because your overall prognosis has to do with what your ejection fraction kind of ends up with. We want it to be the higher, the better. And, of course, should you get pregnant again, absolutely, this can happen again. And unfortunately, there's not one great way to prevent this. You just got to be on the lookout for it and. Or, you know, maybe consider, you know, not getting pregnant again. But those are difficult decisions, obviously, to make. So that is the catch. There is a risk of recurrence here. That's not 100%, thankfully, and it doesn't seem to be 70%. But if a patient recovers fully, the risk of recurrence, based on some of the data, seem to be around 30, maybe 40%. That's pretty darn high. You wouldn't get on a plane that had a 40% chance of going down midair. Okay, well, I hope you wouldn't. So that number is high. And people always say, well, it's not less than 50%. Yeah, but we're talking about something that gets worse as the condition recurs, so something that definitely patients should be aware of. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. We have covered peripartum cardiomyopathy when the left heart falters in this episode. Now that we've done all that, Michael, let's take it home.