الفهرس 
Etiology and PathophysiologyOnly 14 pages are availabe for public view
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Abstract
Peripartum cardiomyopathy is a rare disorder in which left ventricular dysfunction and symptoms of heart failure occur in the peripartum period in previously healthy women. Incidence of PPCM ranges from 1 in 1300 to 1 in 15,000 pregnancies. The etiology of PPCM is unknown, but viral, autoimmune, and idiopathic causes may contribute. The diagnostic criteria are onset of heart failure in the last month of pregnancy or in first 5 months postpartum, absence of determinable cause for cardiac failure, and absence of a demonstrable heart disease before the last month of pregnancy. Risk factors for PPCM include advanced maternal age, multiparity, African race, twinning, gestational hypertension, and long-term tocolysis.
PPCM is a diagnosis of exclusion, distinguished by rapid onset, occurrence in the peripartum period, and the significant improvement in up to 50% of affected women. In the past, the diagnosis of this entity was mostly made on clinical grounds, however modern echocardiographic techniques have allowed more accurate diagnoses by excluding cases of diseases that mimic the clinical symptoms and signs of heart failure.
In general, treatment of PPCM is similar to that for other types of congestive heart failure. Current therapeutic options consist of conventional supportive therapy for congestive heart failure, which also involves salt restriction, and the use of diuretics. Hydralazine is the drug of choice prepartum, in addition to nitrates or amlodipine. Angiotensin-converting enzyme inhibitors are the mainstay of treatment post-partum, even in mothers who are breast-feeding. In the acutely ill or highly symptomatic patients, intravenous preload and after-load reducing agents (nitroprusside, nitroglycerin) or inotropic agents (dobutamine, dopamine, milrinone) should be considered.
As regard the anesthetic management, early administration of labor analgesia to minimize further cardiac stress associated with pain is paramount in the management of these patients. Various analgesic techniques provide unique advantages in the hemodynamic management of the parturient while also providing excellent analgesia by epidural or a continuous spinal anesthesia is usually the best anesthetic option. General anesthesia is sometimes required when cesarean section is required because of non reassuring fetal status or acute maternal decompensation.
Pregnancy has been discouraged in patients with PPCM to avoid the risk of precipitating recurrent or progressive left ventricular dysfunction. Approximately 20% of women with the disorder either die or survive only because they receive cardiac transplants; the majority recovers partially or completely. Although the women who recover may desire to become pregnant again, there is a concern that such pregnancies may be associated with an increased risk of recurrence of cardiomyopathy.
The prognosis of PPCM is related to the recovery of ventricular function. Patients with severe ventricular dysfunction are less likely to survive and recover normal cardiac function. About 50% of patients with PPCM disorder are reported to recover baseline ventricular function within 6 months of delivery. Peripartum cardiomyopathy is a rare disorder in which left ventricular dysfunction and symptoms of heart failure occur in the peripartum period in previously healthy women. Incidence of PPCM ranges from 1 in 1300 to 1 in 15,000 pregnancies. The etiology of PPCM is unknown, but viral, autoimmune, and idiopathic causes may contribute. The diagnostic criteria are onset of heart failure in the last month of pregnancy or in first 5 months postpartum, absence of determinable cause for cardiac failure, and absence of a demonstrable heart disease before the last month of pregnancy. Risk factors for PPCM include advanced maternal age, multiparity, African race, twinning, gestational hypertension, and long-term tocolysis.
PPCM is a diagnosis of exclusion, distinguished by rapid onset, occurrence in the peripartum period, and the significant improvement in up to 50% of affected women. In the past, the diagnosis of this entity was mostly made on clinical grounds, however modern echocardiographic techniques have allowed more accurate diagnoses by excluding cases of diseases that mimic the clinical symptoms and signs of heart failure.
In general, treatment of PPCM is similar to that for other types of congestive heart failure. Current therapeutic options consist of conventional supportive therapy for congestive heart failure, which also involves salt restriction, and the use of diuretics. Hydralazine is the drug of choice pre-partum, in addition to nitrates or amlodipine. Angiotensin-converting enzyme inhibitors are the mainstay of treatment post-partum, even in mothers who are breast-feeding. In the acutely ill or highly symptomatic patients, intravenous preload and afterload reducing agents (nitroprusside, nitroglycerin) or inotropic agents (dobutamine, dopamine, milrinone) should be considered.
As regard the anesthetic management, early administration of labor analgesia to minimize further cardiac stress associated with pain is paramount in the management of these patients. Various analgesic techniques provide unique advantages in the hemodynamic management of the parturient while also providing excellent analgesia by epidural or a continuous spinal anesthesia is usually the best anesthetic option. General anesthesia is sometimes required when cesarean section is required because of non reassuring fetal status or acute maternal decompensation.
Pregnancy has been discouraged in patients with PPCM to avoid the risk of precipitating recurrent or progressive left ventricular dysfunction. Approximately 20% of women with the disorder either die or survive only because they receive cardiac transplants; the majority recovers partially or completely. Although the women who recover may desire to become pregnant again, there is a concern that such pregnancies may be associated with an increased risk of recurrence of cardiomyopathy.
The prognosis of PPCM is related to the recovery of ventricular function. Patients with severe ventricular dysfunction are less likely to survive and recover normal cardiac function. About 50% of patients with PPCM disorder are reported to recover baseline ventricular function within 6 months of delivery.