Peripartum cardiomyopathy underreported in primiparous.

Peripartum cardiomyopathy (PPCM) is a rare form of dilated cardiomyopathy that develops either in late pregnancy or in the first 5 months after delivery. It may occur in childbearing women of any age, but it is most common after age 30. Its incidence varies by geographic location and most cases involve women of African descent. Peripartum cardiomyopathy complicates 1 in every 1,300 to 4,000 deliveries in the United States. The etiology of PPCM remains poorly understood, with theories generally centered on autoimmune mechanisms triggered either by pregnancy or viral infection and in susceptible individuals, with prolonged use of tocolysis. Some of the risk factors associated with this condition include multiple gestations, preeclampsia, alcoholism, smoking, older age, obesity, personal history of cardiac disorders and African-American origin. Proper diagnosis of PPCM is a great challenge. It has no pathognomic features and has symptoms common to many other diseases, including underlying heart disease. The diagnosis therefore, is largely one of exclusion. The prognosis often depends on early diagnosis and the size and systolic function of the dilated heart. Aggressive measures are taken to stabilize, prevent worsening of symptoms and restore ventricular systolic function. It tends to reoccur, often progressing and worsening in subsequent pregnancies. Some patients may require heart transplantation to alleviate their symptoms and improve survival. The death rate associated with PPCM in some series is as high as 25-50%. We present 4 case reports in primiparous teenagers diagnosed with PPCM within a week of delivery. Patients had severe left ventricular dysfunction on admission with ejection fraction 15-20%. Patients' left ventricular systolic function improved to normal over 4 months on [beta]-blockers and angiotensin converting inhibitors. In this case report we discuss the clinical and therapeutic aspect of peripartum cardiomyopathy and emphasize occurrence of PPCM in women of all ages in child bearing group and is especially underreported in primiparous.

Anil K. Goli, MD, Madhav Koduri, MD, Steve Smith, MD, and Stephen A. Fahrig, MD, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN.