The Heart of Maternal Mortality: Postpartum Cardiomyopathy and Its Upstream Determinants of Health

Abstract

CASE: A 25-year-old obese African American female presented with dyspnea 6 weeks after a full-term vaginal delivery complicated by pre-eclampsia. Further work up showed LV enlargement without hypertrophy and globally decreased contractility consistent with postpartum cardiomyopathy as well as endocarditis with vegetations on the aortic and tricuspid valves. In the setting of poor patient compliance, patient progressed to worsening systolic heart failure as LVEF dropped from 45% to 25% within a year. Despite further management including valve replacement, ICD placement and a continuous milrinone treatment, LVEF continued to decline, with the lowest value at 12%. During one of her recurrent acute respiratory failures, the patient and team made the difficult decision to transition to palliative care, where she expired.

BACKGROUND: Postpartum cardiomyopathy (PPCM) is a life-threatening disease that arises between the last month of pregnancy and four months after delivery, where patients present with dyspnea, dizziness, or lower extremity edema. Although it is rare with an incidence of 1 case per 2187 live births, it has a high mortality rate in the US ranging from 6% to 10%, mostly in the first 30 days.

DISCUSSION: Multiple recent studies have demonstrated the significance of early diagnosis of PPCM and its strong association with more favorable outcomes, including greater LVEF recovery and lower rates of morbidity and mortality. This evidence suggests the need for pre-discharge screening, in order to diagnose patients earlier and give them the greatest opportunity for a full recovery. Additionally, patient noncompliance, largely influenced by socioeconomic status and medical literacy of the patient, is another crucial factor that affects the prognosis of PPCM. Effective strategies to increase compliance include educating the patient, using an inter-professional healthcare team, and working with the psychological and socioeconomic barriers to compliance.