Peripartum cardiomyopathy: diagnosis, bromocriptine, recovery and the next pregnancy — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 30-year-old woman presents 2 weeks after a vaginal delivery with orthopnoea and ankle swelling. Echo shows LVEF 28% with LV end-diastolic diameter 62 mm. Coronary disease, valve disease and other causes of heart failure have been excluded. She is not breastfeeding.^[1]

1. Give the ESC 2025 definition of peripartum cardiomyopathy. (2)^[1]
2. Which three diagnostic measures does ESC 2025 say a woman with suspected PPCM should have, and which differential diagnosis should be excluded by CMR? (2)^[1]
3. Name two features in her presentation that ESC 2025 lists as key indicators of risk of complications. (1)^[1]
4. Give the ESC 2025 row on bromocriptine, with class and level, and the row on anticoagulation that accompanies it, with class and level. (2)^[1]
5. Describe the 2017 multicentre randomized study of bromocriptine: population, the two regimens and the rates of full recovery. (2)^[8]
6. Give the ESC 2025 row on wearable cardioverter defibrillators in PPCM, with class and level. (1)^[1]

Model answers — SAQ 1

1. HF with reduced LVEF <45%, without any other cause of HF (1 mark).^[1] Occurring mainly during the peripartum period or in the months following delivery, termination or miscarriage (1 mark).^[1]
2. ECG, natriuretic peptides and echocardiography (1 mark).^[1] Myocarditis is the differential diagnosis to be excluded by CMR (1 mark).^[1]
3. LVEF <30% and LV end-diastolic diameter >60 mm (1 mark).^[1]
4. Bromocriptine may be considered in addition to optimal HF treatment to enhance recovery of LV function in women with PPCM (Class IIb, Level B) (1 mark).^[1] Adding at least prophylactic LMWH treatment to bromocriptine should be considered (Class IIa, Level C) (1 mark).^[1]
5. Multicentre trial of 63 patients with PPCM and LVEF ≤35%, randomly assigned to bromocriptine 2.5 mg for 7 days or 5 mg for 2 weeks then 2.5 mg for 6 weeks, in addition to standard HF therapy (1 mark).^[8] Full recovery (LVEF ≥50%) in 52% of the 1-week group and 68% of the 8-week group (1 mark).^[8]
6. The use of a WCD may be considered in women with PPCM and LVEF <35% (Class IIb, Level C) (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 33-year-old woman had peripartum cardiomyopathy 14 months ago. On heart failure treatment, her LV volumes and LVEF normalised 12 months ago, and a reversible course of heart failure is assumed. Genetic testing found no variant. She asks about stopping treatment and about a further pregnancy.^[1]

1. Give the ESC 2025 row on how long HF treatment should be considered after recovery, with class and level and its condition. (2)^[1]
2. What does ESC 2025 say about stepwise discontinuation, and what risk did recent data indicate after discontinuation? (2)^[1]
3. Give the NHFA/CSANZ 2018 practice advice on stopping neurohormonal antagonists in HF with recovered ejection fraction due to PPCM, and the follow-up it advises. (2)^[5]
4. Give the ESC 2025 row on counselling, with class and level. (1)^[1]
5. Give the AHA/ACC/HFSA 2022 systematic review figures for subsequent pregnancies with persistent LV dysfunction and with recovered LV function. (2)^[4]
6. What does ESC 2025 say about beta-blockade when a new pregnancy is planned after PPCM? (1)^[1]

Model answers — SAQ 2

1. When a reversible course of HF is assumed, treatment in accordance with HF guidelines should be considered for at least 12 months after complete LV recovery, meaning normalization of LV volumes and EF (1 mark).^[1] Class IIa, Level C (1 mark).^[1]
2. Stepwise discontinuation may be considered after 1 year if complete myocardial recovery is achieved, assuming no genetic predisposition has been identified (1 mark).^[1] Recent data indicated a higher risk of LVEF relapse in subsequent pregnancies in women with PPCM who had discontinued HF medication (1 mark).^[1]
3. Cessation can be considered in certain circumstances with specialist advice and close monitoring, such as HF with recovered ejection fraction due to PPCM, where there are no other indications such as hypertension or vascular disease (1 mark).^[5] If the dose is reduced or ceased, close follow-up such as natriuretic peptides and serial imaging of LV size and function should be undertaken or considered (1 mark).^[5]
4. Counselling about the risk of recurrence during a subsequent pregnancy and about contraception is recommended in all cases, even after recovery of LV function (LVEF >50%) (Class I, Level C) (1 mark).^[1]
5. With persistent LV dysfunction (93 subsequent pregnancies): 48% further LVEF deterioration, 49% HF symptoms and 16% mortality (1 mark).^[4] With recovered LV function (98 pregnancies): 27%, 32% and 0% respectively (1 mark).^[4]
6. Discontinuing beta-blockade may not be advisable, and restarting it may be beneficial at a subsequent pregnancy, irrespective of baseline LV systolic function (1 mark).^[1]