Swelling Up from Head to Toe: Postpartum Cardiomyopathy

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It’s 4 AM. CCT is empty. You are doing uWorld questions for your upcoming Step 3. As you are about to drink your warm, cheap coffee, the triage nurse rolls in a 39-year-old female with no significant PMH who is complaining of shortness of breath. The patient notes worsening dyspnea on exertion over the past 4 days with a non-productive cough. There is no shortness of breath at rest; however, she notes difficulty breathing when lying flat. The patient had a full-term vaginal delivery 2 months ago with no complications. Her pregnancy though was complicated by preeclampsia.

The patient denies chest pain, palpitation, dizziness, headache, leg swelling, hemoptysis, abdominal pain, nausea/vomiting, and fever/chills.

Vitals at triage: HR 112; BP 192/110; RR 21; SPO2 97% on room air; Temp 98.8 F

Exam is significant for a young female in mild respiratory distress, AAOx3, Supple neck, no JVD, tachycardia, +crackles at bilateral lower bases, no retractions, soft/non-tender abdomen, +2 LE pitting edema to the knee.

ECG shows Sinus tachycardia.

You suspect Postpartum Cardiomyopathy.

What is your top differential diagnosis?

Pre-existing cardiomyopathy (unmasked by pregnancy)
Valvular heart disease (unmasked by pregnancy)
Hypertensive heart disease
Pulmonary embolism
Pre-existing, unrecognized congenital heart disease

What is Postpartum Cardiomyopathy?

Postpartum cardiomyopathy is also known as pregnancy-induced cardiomyopathy and is a form of dilated cardiomyopathy.

What are the diagnostic criteria for Postpartum Cardiomyopathy?

Development of heart failure in the last month of pregnancy or within 5 months of delivery
Absence of another identifiable cause of heart failure
Absence of recognizable heart disease prior to the last month of pregnancy
LV systolic dysfunction (LVEF < 45%)

What are the most common signs and symptoms of postpartum cardiomyopathy?

Most common symptoms:

Dyspnea (most common)
Cough
Orthopnea
Paroxysmal nocturnal dyspnea
Non-specific fatigue and chest discomfort

Most common signs:

Tachycardia
Peripheral edema
Raised CVP
Diastolic murmur
S3

The clinical presentation and hemodynamic features in postpartum cardiomyopathy are indistinguishable from those other forms of dilated cardiomyopathy.

What are some diagnostic challenges in patients with postpartum cardiomyopathy?

Postpartum cardiomyopathy mimics the changes occurring in normal pregnancy. In addition, its signs and symptoms are similar to any other form of systolic heart failure. However, in contrast to pregnant women with underlying heart disease, symptoms are rarely seen before 36 weeks of gestation, and more than 60% of cases presents during the first 2 months postpartum.

What are risk factors for postpartum cardiomyopathy?

Extremes of reproductive age
High parity/gravidity
Malnutrition/high salt intake
Smoking
Ethnic/socioeconomic factors

Is the management of postpartum cardiomyopathy different from management of other causes of heart failure?

No. In pregnant women with heart failure, the goals of medical therapy are similar to those nonpregnant patients.

What is the prognosis of postpartum cardiomyopathy?

Patients with postpartum cardiomyopathy have the best recovery rate than any other types of dilated cardiomyopathy. 50-60% of patients show complete recovery within 6 months postpartum. However, patients with persistent cardiomegaly at 6 months have a reported mortality of 85% at 5 years.

Special Thanks to Dr. Willis and Dr. DeSouza