Peripartum cardiomyopathy is a rare disorder in which a weakened heart is diagnosed within the final month of pregnancy or within 5 months after delivery.

Cardiomyopathy - peripartum

Cardiomyopathyoccurs when there is damage to the heart. As a result, the heart muscle becomes weak and cannot pump blood efficiently. Decreased heart function affects the lungs, liver, and other body systems.

Peripartum cardiomyopathy is a form of dilated cardiomyopathy in which no other cause of heart dysfunction (weakened heart) can be identified.

In the United States, peripartum cardiomyopathy complicates 1 in every 1,300 - 4,000 deliveries. It may occur in childbearing women of any age, but it is most common after age 30.

Risk factors include obesity, having a personal history of cardiac disorders such as myocarditis, use of certain medications, smoking, alcoholism, multiple pregnancies, being African American, and being malnourished.

• Fatigue
• Feeling of racing heart or skipping beats (palpitations)
• Increased night-time urination (nocturia)
• Shortness of breath with activity and when laying flat
• Swelling of the ankles

During a physical examination, the physician will look for signs of fluid in the lungs by touching and tapping with the fingers. Listening to the chest with a stethoscope will reveal lung crackles, a rapid heart rate, or abnormal heart sounds.

The liver may be enlarged and neck veins may be swollen. Blood pressure may be low or may drop when the patient stands up.

Heart enlargement, congestion of the lungs or the veins in the lungs, decreased cardiac output, decreased movement or functioning of the heart, or heart failure may show on:

• Chest x-ray
• Chest CT scan
• Coronary angiography
• Echocardiogram
• Nuclear heart scan

A heart biopsymay be helpful in determining an underlying cause of cardiomyopathy. Many cases of peripartum cardiomyopathy seem to be related to myocarditis, which can be confirmed by a heart biopsy.

The woman may need to stay in the hospital until acute symptoms subside.

Because the heart dysfunction is usually reversible, and the women are usually young, everything possible will be done to ensure survival.

This may include taking extreme measures such as:

• Use of a balloon heart pump (aortic counterpulsation balloon)
• Immunosuppressive therapy (such as medicines used to treat cancer or prevent rejection of a transplanted organ)
• Heart transplant if severe congestive heart failure persists

For most women, however, treatment focuses simply on relieving the symptoms. Some symptoms resolve on their own without treatment.

Medications include:

• Digitalis to strengthen the heart's pumping ability
• Diuretics (water pills) to remove excess fluid
• Low-dose beta-blockers

A low-salt diet may be recommended. Fluid may be restricted in some cases. Activities, including nursing the baby, may be limited when symptoms develop.

Daily weighing may be recommended. A weight gain of 3 or 4 pounds or more over 1 or 2 days may be a sign of fluid buildup.

Women who smoke and drink alcohol will be advised to stop, since these habits may make the symptoms worse.

There are several possible outcomes in peripartum cardiomyopathy. Some women remain stable for long periods, while others get worse slowly.

Others get worse very quickly and may be candidates for a heart transplant. The death rate may be as high as 25 - 50%.

The outlook is good for women whose hearts returns to normal size after the baby is born. If the heart remains enlarged, future pregnancies may result in heart failure. It is not known how to predict who will recover and who will develop severe heart failure.

Women who develop peripartum cardiomyopathy are at high risk of developing the same problem with future pregnancies and should discuss contraception with their physician.

• Cardiac arrhythmias (can be deadly)
• Congestive heart failure
• Pulmonary emboli (blood clots in the lungs)

Call your health care provider if you are currently pregnant or have recently delivered a baby and think you may have signs of cardiomyopathy.

Also seek medical attention if you develop chest pain, palpitations, faintness, or other new or unexplained symptoms.

Eat a well-balanced, nutritious diet, exercise to increase cardiovascularfitness, and avoid cigarettes and alcohol. Your doctor may advise you to avoid getting pregnant again if you have had heart failure during a previous pregnancy.

Dilated cardiomyopathy is a condition in which the heart becomes weakened and enlarged, and it cannot pump blood efficiently. The decreased heart function can affect the lungs, liver, and other body systems.

There are several different types of cardiomyopathy. Dilated cardiomyopathy is the most common form.

See also:

• Hypertrophic cardiomyopathy
• Ischemic cardiomyopathy
• Restrictive cardiomyopathy

Cardiomyopathy - dilated

There are many causes of dilated cardiomyopathy. Some of these are:

• Alcohol (alcoholic cardiomyopathy) or cocaine abuse
• Atrial fibrillation, supraventricular tachycardia, or other heart rhythm problems in which the heart beats very fast for a long period of time (called Tachycardia-mediated cardiomyopathy)
• Autoimmune illnesses that involve the heart, such as systemic lupus erythematosus and rheumatoid arthritis
• Catecholamine excess from a tumor that releases catecholamines (pheochromocytoma)
• Coronary artery disease (See: Ischemic cardiomyopathy)
• Deficiencies of certain vitamins and minerals (thiamine, calcium, magnesium)
• End-stage kidney disease
• Family history of cardiomyopathy (some cardiomyopathies run in families and have a genetic component)
• Infections that involve the heart muscle, such as viruses, HIV infection, Chagas disease, and Lyme disease
• Inherited disorders such as muscular dystrophy
• Medications that can be toxic to the heart (such as some chemotherapy drugs used to treat cancer)
• Poorly controlled high blood pressure
• Pregnancy (See: Peripartum cardiomyopathy)
• Stress-induced cardiomyopathy
• Trace elements, such as lead, arsenic, or mercury

This condition can affect anyone at any age. However, it is most common in adult men.

The most common causes of dilated cardiomyopathy in children are:

• Heart (coronary) disease
• Myocarditis
• Some infections
• Unknown cause (idiopathic dilated cardiomyopathy)

Symptoms of heart failure are most common. Usually, they develop slowly over time. However, sometimes symptoms start very suddenly and are severe. Common symptoms are:

• Shortness of breath with activity or after lying down (or being asleep) for a while, or in infants while feeding
• Swelling of feet and ankles (in adults)
• Irregular or rapid pulse
• Fatigue, weakness, faintness
• Swelling of the abdomen (in adults)
• Loss of appetite
• Cough

Other symptoms may include:

• Chest pain
• Decreased alertness or concentration
• Failure to thrive (in children)
• Low urine production
• Need to urinate at night (in adults)
• Shock

Cardiomyopathy is usually discovered when the doctor is examining and testing you for the cause of heart failure.

• Tapping over the heart with the fingers and feeling the area may indicate that the heart is enlarged.
• Listening to the chest with a stethoscope reveals lung crackles, heart murmur, or other abnormal sounds.
• The liver may be enlarged.
• Neck veins may be bulging.

A number of laboratory tests may be done to determine the cause:

• Antinuclear antibody (ANA), erythrocyte sedimentation rate (ESR), and other tests to diagnose autoimmune illnesses
• Antibody test to identify infections such as Lyme disease and HIV
• Serum TSH and T4 test to identify thyroid problems

Children will have:

• Poor growth
• Pale skin
• Difficulty feeding
• Weak pulses in the legs and arms

Heart enlargement, congestion of the lungs, decreased movement/functioning of the heart, or heart failure may show on these tests:

• Echocardiogram(ultrasound of the heart)
• Cardiac stress tests
• Cardiac catheterization and coronary angiography
• Chest CT scanor MRI of the heart
• Chest x-ray
• Nuclear heart scan (MUGA, RNV)

Other tests may include:

• ECG
• Heart biopsy

Lab tests vary depending on the suspected cause.

When the cause of the dilated cardiomyopathy can be found, that condition is treated. For example, high blood pressure or coronary artery disease should be treated. If alcohol or cocaine use is the cause, your doctor will ask you to stop using them. Sometimes, no specific cause can be found, but the treatments listed below will still be used.

Attempts are also made to find a "trigger" that may have caused a sudden worsening in a patient's symptoms. Examples include not taking medication correctly, increasing salt or fluid intake, or drinking excess alcohol.

Treatment for cardiomyopathies focuses on treating heart failure. Drugs and treatments that may be used include:

• ACE inhibitors, such as captopril, enalapril, lisinopril, and ramipril
• Angiotensin receptor blockers (ARBs) such as losartan and candesartan
• Beta-blockers, such as carvedilol and metoprolol
• Diuretics, including thiazide, loop diuretics, and potassium-sparing diuretics
• Digitalis glycosides
• Drugs that dilate blood vessels (vasodilators)

See also: Heart failure

Some people may benefit from the following heart devices:

• Single or dual-chamber pacemaker
• Biventricular pacemaker
• Implantable cardioverter-defibrillator
• Left ventricular assist device (LVAD)

A low-salt diet may be prescribed for adults, and fluid may be restricted in some cases. You can usually continue your regular activities, if you are able.

You may be asked to monitor your body weight daily. Weight gain of 3 pounds or more over 1 or 2 days may indicate fluid buildup (in adults).

Avoid smoking and drinking alcohol, which may make the symptoms worse.

If the heart function remains poor, a heart transplant may be considered.

The outcome varies. Some people remain in a stable condition for long periods of time, some continue to gradually get sicker, and others quickly get worse. Cardiomyopathy can only be corrected if the disease that caused it can be cured.

About one-third of children recover completely, one-third recover but continue to have some heart problems, and one-third die.

• Arrhythmias
• Congestive heart failure
• Pulmonary edema
• Side effects of medications, including:
  • Headache
  • Gastrointestinal upset
  • Light-headedness and fainting
  • Low blood pressure
  • Lupus reaction (a group of symptoms including a skin rash and arthritis)

Call your health care provider if you have symptoms of cardiomyopathy.

If chest pain, palpitations, or faintness develop seek emergency medical treatment immediately.

• Eat a well-balanced and nutritious diet
• Exercise to improve heart fitness
• Stop smoking
• Minimize alcohol consumption

Hare JM. The dilated, restrictive, and infiltrative cardiomyopathies. Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 64.

Wexler RK, Elton T, Pleister A, Feldman D. Cardiomyopathy: An overview. Am Fam Physician. 2009;79:778-784.

Bernstein D. Diseases of the myocardium. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 439.

A C-section, also called a cesarean section, is the delivery of a baby through a surgical opening in the lower belly area.

Abdominal delivery; Abdominal birth; Cesarean section

A C-section delivery is performed when a vaginal birth is not possible or is not safe for the mother or child.

Surgery is usually done while the woman is awake but numbed from the chest to the feet. This is done by giving her epidural or spinal anesthesia.

The surgeon make a cut across the belly just above the pubic area. The uterus and amniotic sac are opened, and the baby is delivered.

The health care team clears the baby's mouth and nose of fluids, and the umbilical cord is clamped and cut. The pediatrician or nurse makes sure that the infant's breathing is normal and that the baby is stable.

The mother is awake, and she can hear and see her baby. The father or another support person is often able to be with the mother during the delivery.

The decision to have a C-section delivery can depend on the obstetrician, the delivery location, and the woman's past deliveries or medical history. Some reasons for having C-section instead of vaginal delivery are:

Reasons related to the baby:

• Abnormal heart rate in the baby
• Abnormal position of the baby in the uterus such as crosswise (transverse) or feet-first (breech)
• Developmental problems such as hydrocephalus or spina bifida
• Multiple babies in the uterus (triplet and some twin pregnancies)

Reasons related to the mother:

• Active genital herpes infection
• Large uterine fibroids low in the uterus near the cervix
• HIV infection in the mother
• Previous uterine surgery, including myomectomy and previous C-sections
• Severe illness in the mother, including heart disease, toxemia, preeclampsia or eclampsia

Problems with labor or delivery:

• Baby's head is too large to pass through mother's pelvis (cephalopelvic disproportion)
• Prolonged or arrested labor
• Very large baby (macrosomia)

Problems with the placenta or umbilical cord:

• Placenta attaches in abnormal location (placenta previa)
• Placenta prematurely separated from uterine wall (placenta abruptio)
• Umbilical cord comes through the cervix before the baby (umbilical cord prolapse)

A C-section is a safe procedure. The rate of serious complications is extremely low. However, certain risks are higher after C-section than after vaginal delivery. These include:

• Infection of the bladder or uterus
• Injury to the urinary tract
• Injury to the baby

A C-section may also cause problems in future pregnancies. This includes a higher risk for:

• Placenta previa
• Placenta growing into the muscle of the uterus and has trouble separating after the baby is born (placenta accreta)
• Uterine rupture

All surgeries carry risks. Risks due to anesthesia may include:

• Reactions to medications
• Problems breathing

Risks related to surgery in general may include:

• Bleeding
• Blood clots in the leg or pelvic veins
• Infection

Most mothers and infants recover well, with few problems.

Women who have C-section deliveries can have a normal vaginal delivery with later pregnancies, depending on the type of C-section performed and the reason the C-section was performed.

Many women who attempt a vaginal birth after cesarean (VBAC) delivery are successful. However, there is a small risk of uterine rupture associated with VBAC attempts, which can endanger the mother and the baby. It is important to discuss the benefits and risks of VBAC with your obstetric health care provider.

The average hospital stay after C-section is 2 to 4 days. Recovery takes longer than it would from a natural birth. Walking is encouraged the day of surgery to speed recovery. Pain can be managed with medications taken by mouth.

Landon MB. Cesarean delivery. In: Gabbe SG, Niebyl JR, Simpson JL, ed. Obstetrics: Normal and Problem Pregnancies. 5th ed. New York, NY: Churchill Livingstone; 2007: Chap.19.