Learning Zone: Peripartum Cardiomyopathy. Dr Helen Kennedy

Topic of the month Date
Peripartum Cardiomyopathy
April 2021
Relevant recent publications
Peripartum Cardiomyopathy BMJ 2019; 364: k5287

Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association. June 2020.

Pathophysiology, diagnosis and management of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy European Journal Heart Failure 2019; 21(7): 827-843.

Pregnancy outcomes in women with heart disease: the CARPREG II study Journal of the American College of Cardiology 2018; 71: 2419–30.

Peripartum Cardiomyopathy Circulation 2016; 133: 1397-1409.

Obstetric anaesthesia management of the patient with cardiac disease International Journal of Obstetric Anaesthesia 2019; 37, 73-85
    OAA webcasts (in last 4 years) Cardiac Disease in pregnancy.
    Prof Cathy Nelson-Piercy
    Three Day Course in Obstetric Anaesthesia, Church House: Day 2 Tuesday 5th November 2019.
    (password: contact the Secretariat)

    Cardiac disease / pregnancy.
    Dr Katrijn Jansen
    OA19 Newcastle Day 1: Thursday 23rd May 2019
    (password: contact the Secretariat)

    Cardiac Issues.
    Dr Vinnie Sodhi
    Obstetric Anaesthesia Management Day, RCP: Friday 5th October 2018
    (password: contact the Secretariat)

    Cardiac disease in obstetric patients.
    Dr Aisling Carroll
    Three Day Course in Obstetric Anaesthesia: Wednesday 8th November 2017.
    (password: contact the Secretariat)

    The parturient with cardiac disease.
    Dr Fiona Walker
    Three Day Course in Obstetric Anaesthesia: Wednesday 9th November 2016.
    (password: contact the Secretariat)

     OAA posters (in last 4 years) Obstetric Anaesthesia Conference May 2020 (Birmingham)

    Peripartum management of a patient with dilated cardiomyopathy M Webb

    Peripartum cardiomyopathy: a diagnostic dilemma A Dhadda

    Obstetric Anaesthesia Conference May 2019 (Newcastle)

    First presentation of peripartum cardiomyopathy with Out-Of-Hospital cardiac arrest in late puerperium E Poimenidi

    Peripartum cardiomyopathy - Bromocriptine as a novel and effective treatment G Longobardi

    A case of severe peripartum cardiomyopathy successfully managed with extracorporeal membrane oxygenation C Griffiths

    Obstetric Anaesthesia Conference May 2017 (Brussels)

    A review of peripartum cardiomyopathy cases presenting over a three-year period P Dhar

    MBRRACE-UK MBRRACE Slide Presentations:

    Saving Lives – Overall messages for cardiovascular disease care – Nov 19
    Saving Lives – Cardiac arrhythmia, SADs and myocardial disease – Nov 19
    Saving Lives – The pathology of cardiovascular deaths – Nov 19
    Saving Lives – Dissection, ischaemia, myocardial & congenital disease Dec 2016

    All links can be accessed here
     National Guidelines
    Cardiac Disease and Pregnancy
    RCOG Good Practice Guideline no.13 June 2011

    RCPSG: Addressing the Heart of the Issue: Good clinical practice in the shared obstetric and cardiology care of women of childbearing age.

    Intrapartum care for women with existing medical conditions or obstetric complications and their babies
    NICE guideline [NG121] March 2019

    Intrapartum care: existing medical conditions and obstetric complications. Quality standard [QS192] February 2020

    Acute care toolkit 15 ACT pregnancy. Managing acute medical problems in pregnancy (management of chest pain, palpitations, breathlessness) Royal College of Physicians Nov 19

      International Guidelines
      2018 ESC Guidelines for the Management of Cardiovascular Diseases During Pregnancy: Section 8. Cardiomyopathies and heart failure: 8.1 Peripartum cardiomyopathy. Full guideline available here

      Pregnancy and Heart Disease 2019
      ACOG: American College of Obstetricians and Gynaecologists. Practice Bulletin No. 212

      Audit / Qu suggestions
      Raising the Standards: RCoA Quality Improvement Compendium:

      Obstetrics 7.9 Timely anaesthetic involvement in the care of high-risk and critically ill women (page 260)

        FRCA questions No previous FRCA question on Peripartum Cardiomyopathy

        Please find example CRQ below

        Cardiomyopathy Example CRQ  a) What are the diagnostic criteria for peripartum cardiomyopathy? (4 marks)

        • Heart failure developing towards the end of pregnancy or up to five months post-partum
        • Absence of another identifiable cause of cardiac failure
        • Absence of cardiac symptoms or disease prior to late pregnancy
        • Left ventricular dysfunction - defined as an ejection fraction less than 45% or reduced fractional shortening of less than 30%

        b) What are the risk factors for peripartum cardiomyopathy? (4 marks)

        • Maternal age >30 yrs
        • Multiparity
        • Ethnic group – e.g. African descent
        • Obesity
        • Multiple pregnancy
        • Pregnancy associated hypertensive disorders
        • Essential hypertension
        • Tocolytic therapy with β-agonists
        • Cocaine use

        c) What are the anaesthetic management aims during labour for a woman with peripartum cardiomyopathy, and how can these be achieved? (12marks)

         Anaesthetic Aims  Management strategies
         Maintain myocardial perfusion  
        - avoid hypotension
        - avoid tachycardia
        - avoid arrhythmia
         Consider invasive blood pressure monitoring
        Smooth induction of general anaesthetic
        Titrated combined spinal epidural technique
        Maintain intravascular volume
        ECG monitoring and early intervention
         Reduce myocardial workload  
         - avoid catecholamine surges  Early epidural
        Opiates to attenuate response to laryngoscopy
        Good intra and post-operative analgesia e.g. Continue epidural post-operatively
         Optimise cardiac output  
        - maintain preload
        - maintain/increase contractility
        - prevent increased afterload/ reduce systemic vascular resistance.
        Consider cardiac output monitoring
        Avoid prolonged Valsalva – consider instrumental second stage of labour
        Neuraxial anaesthesia achieves this better than general anaesthesia
        Avoid aortocaval compression
        Neuraxial anaesthesia
        Try to avoid ergometrine

        Suggested resources:

        Ratnayake G, Patil, V. Anaesthetic Management in Peripartum Cardiomyopathy. Journal of Anaesthesia and Intensive Care Medicine 2018; 6(1): 555677. DOI: 10.19080/JAICM.2018.06.555677
        Available at: https://juniperpublishers.com/jaicm/pdf/JAICM.MS.ID.555677.pdf

        Ibrahim IR, Sharma V. Cardiomyopathy and anaesthesia. BJA Education 2017; 17(11): 363-369. DOI: 10.1093/bjaed/mkx022
        Available at: https://academic.oup.com/bjaed/article/17/11/363/3868553

        Burt C, Durbridge J. Management of cardiac disease in pregnancy. BJA Education 2009; 9(2): 44-47. DOI: 10.1093/bjaceaccp/mkp005
        Available at: https://academic.oup.com/bjaed/article/9/2/44/299573

        Ray P, Murphy GJ, Shutt LE. Recognition and management of maternal cardiac disease in pregnancy. British Journal of Anaesthesia 2004; 93(3): 428-439. DOI: 10.1093/bja/aeh194
        Available at: https://www.bjanaesthesia.org.uk/article/S0007-0912(17)35890-7/fulltext

        Simulation suggestion


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