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

Stem

Practice viva. The examiner asks how you define and diagnose peripartum cardiomyopathy, how you manage a pregnant woman in cardiogenic shock, where bromocriptine and anticoagulation fit, and what you tell a woman who has recovered and wants another baby.^[1]

Branch A — Definition and diagnosis

Examiner: A woman is breathless 3 weeks after delivery and her LVEF is 35%. When do you call this peripartum cardiomyopathy?^[1]

Strong answer:

• ESC 2025 defines it as 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]
• AHA/ACC/HFSA 2022 defines it as systolic dysfunction, typically LVEF <45%, often with LV dilation, in late pregnancy or early postpartum with no other identifiable cardiomyopathy cause.^[4]
• Diagnostic measures should include ECG, natriuretic peptides and echocardiography, and myocarditis should be excluded by CMR (ESC 2025).^[1]
• Mild to moderate symptomatic cases of PPCM are often mistaken for physiological changes associated with pregnancy, especially in the post-partum period (ESC 2025).^[1]

Follow-up: Does she need genetic testing?^[1]

• Genetic counselling and testing should be considered in women with PPCM (ESC 2025, Class IIa, Level C; ESC 2023 cardiomyopathies has the same class and level).^[1][2]
• ESC 2025 reports variants in TTN, FLNC, BAG3 and DSP in up to 15% of women with PPCM, TTN truncating variants being the most common.^[1]

Branch B — Cardiogenic shock in pregnancy

Examiner: Another woman, at 34 weeks with PPCM, is in cardiogenic shock. The foetus is viable. What does ESC 2025 recommend?^[1]

Strong answer:

• In pregnant women with cardiogenic shock, inotropes and/or vasopressors are recommended, with levosimendan, dobutamine and milrinone as the recommended agents (Class I, Level C); levosimendan is given without a loading dose and adrenaline should be avoided.^[1]
• In cardiogenic shock, urgent delivery by caesarean section is recommended as soon as the foetus is viable, taking gestational age, comorbidities and the available level of medical care into account (Class I, Level C).^[1]
• Early transfer to a facility providing mechanical circulatory support should be considered (Class IIa, Level C), and in PPCM mechanical support should be considered in persistent cardiogenic shock despite medical treatment.^[1]

Follow-up: Which heart failure drugs does ESC 2025 not recommend during pregnancy?^[1]

• ACE-Is, ARBs, ARNIs, MRAs, ivabradine and SGLT2 inhibitors are not recommended during pregnancy due to adverse foetal effects (ESC 2025, Class III, Level C).^[1]
• AHA/ACC/HFSA 2022 adds vericiguat to its list of drugs that should not be administered in women with HF or cardiomyopathy who are pregnant or currently planning for pregnancy, because of significant risks of fetal harm (COR 3: Harm, LOE C-LD).^[4]

Branch C — Bromocriptine and anticoagulation

Examiner: After delivery, LVEF is 25%. Would you give bromocriptine?^[1]

Strong answer:

• ESC 2025 says bromocriptine may be considered in addition to optimal HF treatment to enhance recovery of LV function (Class IIb, Level B), and that adding at least prophylactic LMWH should be considered (Class IIa, Level C).^[1]
• It says the downsides of stopping lactation, a secondary effect of bromocriptine, include psychological implications for the mother and the loss of the infant’s source of nutrition, and that these considerations indicate that women with moderate and severe HF in PPCM are the preferred candidates for bromocriptine.^[1]
• In the 2017 multicentre randomized study of 63 patients with PPCM and LVEF ≤35%, given 1 week or 8 weeks of bromocriptine in addition to standard heart failure therapy, full recovery (LVEF ≥50%) was present in 52% of the 1-week group and 68% of the 8-week group; no significant differences were observed between 1-week and 8-week treatment, with a trend for better full recovery in the 8-week group.^[8]
• AHA/ACC/HFSA 2022 calls its efficacy and safety for acute PPCM uncertain.^[4]

Follow-up: What about anticoagulation without bromocriptine?^[1][4]

• ESC 2025 recommends therapeutic-dose LMWH in pregnant women with intracardiac thrombus or decreased LV function with EF <35% (Class I, Level C).^[1]
• AHA/ACC/HFSA 2022 says that in acute HF caused by PPCM with LVEF <30%, anticoagulation may be reasonable at diagnosis until 6 to 8 weeks postpartum, although efficacy and safety are uncertain (COR 2b, LOE C-LD).^[4]

Branch D — Recovery and the next pregnancy

Examiner: Her LV volumes and LVEF normalise. She wants to stop her tablets and have another baby. What do you say?^[1]

Strong answer:

• When a reversible course is assumed, ESC 2025 says HF-guideline treatment should be considered for at least 12 months after complete LV recovery (Class IIa, Level C); stepwise discontinuation may be considered after 1 year if recovery is complete and no genetic predisposition has been identified.^[1]
• Counselling about the risk of recurrence in a subsequent pregnancy and about contraception is recommended in all cases, even after recovery of LV function (ESC 2025, Class I, Level C).^[1]
• ESC 2025 says women with recovered LV function remained at risk of relapse, and that stopping beta-blockade may not be advisable when a new pregnancy is planned.^[1]
• AHA/ACC/HFSA 2022 names LVEF <50% before a subsequent pregnancy as the strongest prognostic determinant.^[4]