Peripartum cardiomyopathy: diagnosis, bromocriptine, recovery and the next pregnancy — practice case: post-partum heart failure

Presentation

Practice case (not a real patient). A 31-year-old woman in Australia presents 3 weeks after delivering her second child with breathlessness on minimal exertion (NYHA class III) and orthopnoea. Her midwife had attributed the breathlessness to normal post-partum recovery.^[1] Echo shows LVEF 28% with no intracardiac thrombus. Coronary disease, valve disease and other causes of heart failure are excluded. She would like to breastfeed if possible.^[1]

Step 1 — Diagnosis

Discussion:

• She meets the ESC 2025 definition: HF with reduced LVEF <45%, without any other cause of HF, occurring mainly during the peripartum period or in the months following delivery, termination or miscarriage; it is essentially a diagnosis of exclusion that requires urgent management.^[1]
• Mild to moderate symptomatic cases are often mistaken for physiological changes of pregnancy, especially post-partum, but most women with PPCM present with acute HF with severe symptoms (NYHA III/IV) (ESC 2025).^[1]
• Diagnostic measures should include ECG, natriuretic peptides and echocardiography, and myocarditis should be excluded by CMR (ESC 2025).^[1]
• Genetic counselling and testing should be considered in women with PPCM (ESC 2025, Class IIa, Level C).^[1]

Step 2 — Heart failure treatment after delivery

Discussion:

• ESC 2025 recommends optimizing HF guideline-directed medical therapy after delivery, taking contraindicated drugs during lactation into account (Class I, Level C).^[1]
• In the post-partum period, full HF treatment can be initiated, except when lactation and breastfeeding are necessary for nutritional reasons, when ARBs and SGLT2 inhibitors should be avoided; spironolactone is considered safe (ESC 2025).^[1]
• Because of the high metabolic demands of lactation, avoiding lactation may be considered in women with severe HF (ESC 2025, Class IIb, Level C).^[1]
• AHA/ACC/HFSA 2022 says breastfeeding may even be associated with LV recovery, and that women who breastfeed can start an ACEi (enalapril or captopril preferred), with metoprolol the preferred beta-blocker.^[4]

Step 3 — Bromocriptine and anticoagulation

Discussion:

• After discussion she chooses not to breastfeed. Bromocriptine may be considered in addition to optimal HF treatment to enhance recovery of LV function (ESC 2025, Class IIb, Level B); a secondary effect is stopping lactation.^[1]
• If bromocriptine is given, adding at least prophylactic LMWH should be considered (ESC 2025, Class IIa, Level C).^[1]
• The ESC 2025 Class I row for therapeutic LMWH applies to pregnant women with intracardiac thrombus or decreased LV function with EF <35%; AHA/ACC/HFSA 2022 says that in women with acute HF caused by PPCM and LVEF <30%, anticoagulation may be reasonable at diagnosis, until 6 to 8 weeks postpartum, although its efficacy and safety are uncertain (COR 2b, LOE C-LD).^[1][4]
• In ESC 2025 Figure 22, on acute HF and cardiogenic shock in pregnancy and up to 6 months post-partum, bromocriptine appears as "If delivered: Bromocriptine (Class IIb)", with a footnoted starting dose of 2.5 mg twice daily with up-titration if needed.^[1]

Step 4 — Rhythm and sudden death

Discussion:

• PPCM may cause ventricular tachyarrhythmias, so she should be monitored (ESC 2025).^[1]
• With LVEF <35%, a wearable cardioverter defibrillator may be considered (ESC 2025, Class IIb, Level C).^[1]
• ESC 2023 cardiomyopathies says thresholds for early ICD implantation in PPCM should be higher than in other conditions because of a high rate of spontaneous recovery after delivery.^[2]

Step 5 — Recovery and duration of treatment

At 6 months her LVEF is 58% with normal LV volumes; no genetic variant was found.^[1]

Discussion:

• ESC 2025 defines myocardial recovery as LVEF >50% and reports it in 46% of women at 6 months.^[1]
• When a reversible course is assumed, treatment in accordance with HF guidelines should be considered for at least 12 months after complete LV recovery (ESC 2025, Class IIa, Level C).^[1]
• In Australia, NHFA/CSANZ 2018 recommends continuing neurohormonal antagonists at target doses in HF with recovered ejection fraction unless a reversible cause has been corrected (strong recommendation for; low quality of evidence).^[5]
• Its practice advice says cessation can be considered with specialist advice and close monitoring in HF with recovered ejection fraction due to PPCM, when there is no other indication; close follow-up should then be undertaken or considered.^[5]

Step 6 — Another pregnancy

Discussion:

• Counselling about the risk of recurrence in a subsequent pregnancy and about contraception is recommended in all cases, even after recovery of LV function (LVEF >50%) (ESC 2025, Class I, Level C).^[1]
• ESC 2025 says women with recovered LV function remained at risk of relapse, and that recent data indicated a higher risk of LVEF relapse in subsequent pregnancies in women who had discontinued HF medication.^[1]
• If she plans another pregnancy, discontinuing beta-blockade may not be advisable, and restarting it may be beneficial in the subsequent pregnancy (ESC 2025).^[1]
• Fail: attributes her symptoms to normal post-partum recovery, continues an ARB while breastfeeding when breastfeeding is needed for nutrition, gives bromocriptine without LMWH, or tells her a further pregnancy is risk-free because her LVEF has recovered.^[1]