Pregnancy complicated by peripartum cardiomyopathy and preeclampsia

Aims: Peripartum cardiomyopathy is an increasingly recognized condition with a prevalence of approximately 1:1,500 in Germany. Complete recovery occurs in 50-75% of all cases after 3-6 months. Hypertensive diseases of pregnancy (e.g., gestational hypertension, preeclampsia) affect approximately 10% of all pregnancies and are well-known complications in the field of gynaecology and obstetrics. However, clinical awareness of the interplay between these two cross-disciplinary entities is scarce. This educational presentation aims to raise the awareness of cardiologists about prevalence, association and dangers of peripartum cardiomyopathy and preeclampsia. Means for appropriate patient surveillance as well as therapeutic approaches will be discussed.

Case summary: A 24-year-old female patient presented to the cardiac intensive care unit (CCU) of our German tertiary care centre as a transfer from a smaller hospital. She had been admitted there on the same day by her obstetrician because of progressive dyspnoea as well as peripheral oedema. In addition, severe arterial hypertension was present (systolic blood pressure 200 mmHg). The course of pregnancy was reported as unremarkable. The symptoms started after an upper respiratory infection 3 weeks ago. Therefore, the obstetrician raised the suspected diagnosis of a cardiomyopathy of unknown origin, potentially myocarditis. Upon presentation to our CCU, the patient was conscious, experiencing improvement of her respiratory distress and hypertension (160/90 mmHg) after initial diuretic treatment. The blood count reported no pathologies; transaminases (ASAT 42 U/l), creatinine (1.20 mg/dl) and CRP (9 mg/l) were slightly elevated. High-sensitive Troponin I was 34 pg/ml. However, NT-proBNP was 37,951 ng/l. Severe albuminuria (1,233 mg/l; 964 mg/g creatinine) was measured leading to the diagnosis of severe preeclampsia. Echocardiography revealed a suspected peripartum cardiomyopathy with a left ventricular ejection fraction of 30%, TAPSE 25 mm and normal cardiac diameters, but extensive pleural effusion. Myocarditis was less likely due to the moderate Troponin levels. A cardiotocogram and duplex of the umbilical vessels revealed the foetus to be in critical distress. An urgent C-section was performed. The female newborn was invasively ventilated in the neonatologic ICU overnight and extubated the following day. A cardiac magnetic resonance imaging excluded myocarditis as the aetiology of the maternal heart failure, hereby strengthening the diagnosis of peripartum cardiomyopathy. Mother and daughter were discharged after 3 weeks hospitalisation in good condition. The cardiac function was restored after 8 weeks of bromocriptine and 4 months of medical heart failure treatment.

Illustration: Video loops of echocardiography at admission and 4-month follow-up will be demonstrated. In addition, pictures of the cardiotocogram as well as the umbilical vessel duplex will be shown. All patient-related data are anonymised.