Can't catch her breath: peripartum cardiomyopathy.
Those who teach childbirth education classes may be serving those with peripartum cardiomyopathy. Because many symptoms of cardiomyopathy are similar to other pregnancy related conditions, these mothers often experience a delay in diagnosis. Those who teach childbirth education classes may be referred for further care.
What is Peripartum Cardiomyopathy?
You may have a client diagnosed with this heart condition. Most expecting mothers are unaware of what peripartum cardiomyopathy is and childbirth education providers can empower women with information about the disease including the symptoms, how it is diagnosed and treatments. Peripartum cardiomyopathy is "defined as development of heart failure secondary to left ventricle systolic dysfunction towards the end of pregnancy or in the months following delivery, without other identifiable causes for dysfunction of the heart" (Biteker, Kayatas, Duman, Turkmen, & Bozkurt, 2014, p. 317). This disease develops because of the pregnancy, and is not the same as other cardiomyopathies (Hilfiker-Kleiner, Haghikia, Nonhoff, & Bauersachs, 20i5). Peripartum cardiomyopathy is a potentially life-threatening cardiovascular complication.
Once thought to be idiopathic, the disease is often related to chronic hypertension, undiagnosed mitral stenosis, obesity, preeclampsia, anemia, and other complications (Akpinar, Ipekci, Gulen, & Ikizceli, 2015). The condition was formerly referred to as "postpartum cardiomyopathy" but new research shows symptoms can occur during pregnancy as well. It is not uncommon to have early diagnosis between the 17th and 36th week of gestation (Biteker et al., 2014). A mother may experience symptoms in the last month of pregnancy or earlier, or as late as five months after delivery.
What are the Signs and Symptoms?
Signs and symptoms of peripartum cardiomyopathy may present as early as the 17th week of gestation and a practitioner may review these with her patient early in her pregnancy. These symptoms can include the following: dyspnea, dizziness, chest pain, cough, fatigue, and peripheral edema. Shortness of breath is the most common presenting symptom with patients stating they are having a hard time catching their breath (Patel, Berg, Barasa, Begley, & Schaufelberger, 2015). A mother is more likely to develop these symptoms if she has also been diagnosed with risk factors such as hypertension and pre-eclampsia during her pregnancy (Fett, 2014).
Because the symptoms associated with peripartum cardiomyopathy overlap with other diagnoses and normal complaints during pregnancy, her health care practitioner has to rule out other diagnoses as well. These differential diagnoses include:
* myocardial infarction
* severe pre-eclampsia
* amniotic fluid embolism
* pulmonary thrombo-embolism
* drug toxicity and others (Okeke, Ezenyeaku, & Ikeako, 2013)
How is Peripartum Cardiomyopathy Diagnosed?
The practitioner will begin with a thorough history and physical exam including when the symptoms began, the duration, severity, and what alleviates them. Some of the tests used to diagnose peripartum cardiomyopathy include the following: ECHO, ECG, chest X-Ray, BNP and cardiac MRI. An ECHO is used to assess overall cardiac function, and shows the ejection fraction, which indicates heart failure. The BNP, a bloodwork test, is a marker for acute heart failure and its severity. Performing an ECG measures and gives a picture of the electrical function of the heart. A chest X-Ray can show if there is increased cardiac size, and if there are any pleural effusions, or fluid in the lungs. The cardiac MRI is used to determine myocardial contraction (Okeke et al., 2013). Criteria for diagnosing peripartum cardiomyopathy include a positive physical exam and history, a BNP of greater than 200, cardiac damage noted on the MRI, cardiac enlargement or pleural effusions seen on X-ray, and an EF less than 45% ( Hilfiker-Kleiner et al., 2015). These tools in conjunction with a physical assessment assist the practitioner to make an accurate clinical diagnosis.
What are the Treatment Options?
Once the diagnosis is made treatment options will be considered with the patient. Treatment will vary depending on whether the patient is still pregnant. Overall, treatment of peripartum cardiomyopathy follows a similar plan to conventional heart failure treatment. Depending on the severity of the disease, the patient may be admitted to the hospital for close cardiac monitoring and supplemental oxygen. Untreated peripartum cardiomyopathy may lead to congestive heart failure, arrhythmias, clots, and sudden death (Akpinar et al., 2015). The patient will be placed on dietary sodium restriction and medications immediately. Pharmacological therapy should include diuretics, vasodilators, and digoxin (Akpinar et al., 2015). ACE inhibitors and spironolactone are contraindicated during pregnancy. Because patients with this disease are at high risk for development of thrombosis and thromboembolism due to pregnancy-related hyper-coagulation as well as blood stasis associated with severe systolic dysfunction, anticoagulants must be considered (Akpinar et al., 2015). The recommended anticoagulant use varies depending on pregnancy. Heparin should be used during pregnancy and warfarin can be started postpartum. (Okeke et al., 2013).
Implications for Future Pregnancies
Once a patient has been diagnosed with peripartum cardiomyopathy, recommendations for future pregnancies should be made. The recommendation will differ depending on recovery. If the mother has made a full recovery with normal heart function, future pregnancy is not contraindicated. However, if the ECHO shows there is an incomplete recovery of cardiac function after treatment, future pregnancy should be deferred while further treatment is attempted (Fett, 2014). However, any "consecutive pregnancy carries a recurrence risk of 30-50%" (Apkinar et al., 2015, p.1282). Even if a patient's EF has returned to normal she should still be given consultation regarding the reoccurrence risk in future pregnancies.
Considerations for Childbirth Educators
Childbirth educators may have mothers diagnosed with peripartum cardiomyopathy. Because these moms may tire faster, childbirth educators should consider teaching more classes that are shorter in length. Home visits might be offered and private classes may better facilitate learning. Classes during pregnancy and postpartum provide an opportunity to present, discuss, and empower expecting mothers with information on common signs and symptoms. Educators may direct mothers to online resources such as cardiomyopathy.org and http://www.hopkinsmedicine.org
Akpinar, G., Ipekci, A., Gulen, B., & Ikizceli, I. (20i5). Beware Postpartum Shortness of Breath. Pakistan Journal of Medical Sciences, 31(5), 1280-1282. http://doi.org/10.12669/pjms.315.8060
Biteker, M., Kayatas, K., Duman, D., Turkmen, M., & Bozkurt, B. (2014). Peripartum Cardiomyopathy: Current State of Knowledge, New Developments and Future Directions. Current Cardiology Reviews, 10(4), 3^-326. http:// doi.org/10.2174/1573403X10666i40320144048
Fett, J. D. (2014). Peripartum cardiomyopathy: A puzzle closer to solution. World Journal of Cardiology, 6(3), 87-99. http://doi.org/10.4330/wjc.v6.13.87
Hilfiker-Kleiner, D., Haghikia, A., Nonhoff, J., & Bauersachs, J. (2015). Peripartum cardiomyopathy: current management and future perspectives. European Heart Journal, 36(18), 1090-i097. http://doi.org/10.1093/eurheartj/ehv009
Okeke, T., Ezenyeaku, C., & Ikeako, L. (20i3). Peripartum Cardiomyopathy. Annals of Medical and Health Sciences Research, 3(3), 313-319. http://doi. org/10.4103/2141-9248.117925
Patel H., Berg M., Barasa A., Begley C., & Schaufelberger M. (2015). Symptoms in women with Peripartum Cardiomyopathy: A mixed method study. Midwifery, 32, 14-20
Caitlin Bruner is a Masters student in the Family Nurse Practitioner program at Tennessee State University, and received her Bachelor of Science in Nursing at Saint Louis University. She is a Registered Nurse in the Post Anesthesia Care Unit at Williamson Medical Center, and a float pool nurse at Summit Medical Center in Nashville, Tennessee.
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|Publication:||International Journal of Childbirth Education|
|Date:||Oct 1, 2016|
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