**11. Delivery**

*Inflammatory Heart Diseases*

transplant facilities.

*10.3.1 Wearable cardioverter-defibrillators*

**10.4 Medical investigational therapy**

safety have not been established.

in patients with PPCM [29].

*10.4.2 Immunosuppressive therapy*

*10.4.3 Intravenous immunoglobulin*

complications.

*10.4.1 Bromocriptine*

patients who were younger and had fewer comorbidities. The rates of myocardial function recovery were poor, 6% in the PPCM group and 2% in without PPCM [27]. According to the older literature, the transplantation was performed in up to one-third of PPCM patients, whereas the contemporary reports demonstrate that transplantation rates vary from 4 to 23% of patients [28]. Hence PPCM patients with significant LV systolic dysfunction should be managed at a tertiary center with

In a large study, it is found that the long-term survival in transplanted PPCM patients was worse compared with all others undergoing transplantation. PPCM patient who received a cardiac transplant had higher mortality, higher incidence of rejection, poorer graft survival, and higher retransplantation rates. Younger patient age, higher allosensitization, higher pretransplant acuity, and increased rejection rates are all important factors for poorer outcomes in these PPCM patients [28].

Further multicenter trial would be valuable to establish if these devices are

Following therapies are not recommended for PPCM patients as its efficacy and

The use of bromocriptine therapy in PPCM patients is controversial. The preliminary data have shown a benefit of bromocriptine in PPCM patients, but further studies are needed to establish safety and efficacy; it is suggested not to routinely use bromocriptine in PPCM patients. Its use is based upon experimental animal studies of prevention of PPCM by prolactin blockade with bromocriptine. Smaller and observational reports showed the beneficial response to bromocriptine therapy

A multicenter study showed that the rate of full recovery (LVEF ≥ 50%) was not significantly higher in the 8-week group compared with the 1-week group. The patients in this trial had better outcomes than observed in prior series, but a placebo control group was not included in the study [30]. One should start anticoagulation in PPCM patients treated with bromocriptine, as the risk of thromboembolic

The advantage of immunosuppressive therapy has been found to be useful in PPCM patients with biopsy-proven myocarditis, but its efficacy is unclear, and empiric immunosuppression in the absence of evidence of a responsive form of myocarditis is not recommended [31]. These medications have significant side

This therapy is tried in patients with myocarditis or newly onset dilated cardiomyopathy with no clear evidence of clinical benefit, and the efficacy of this

approach has not been confirmed in any type of myocarditis.

beneficial; in a single smaller study, it was found to be useful.

**118**

effects.

In PPCM patient the risks and benefits of early delivery should be considered and discussed. The 2010 European Society of Cardiology working group statement advised that early delivery is not required if the maternal and fetal conditions are stable. But the patient-related factors, gestational age, cervical status, fetal status, and the potential cardiovascular impact of continuing pregnancy must be considered in timing delivery. The decisions regarding timing and mode of delivery should be based on combined multidisciplinary meeting. In PPCM patients with advanced heart failure, prompt delivery of fetus is indicated for maternal cardiovascular indications and hemodynamic instability. The elective cesarean delivery is preferred for PPCM patients with advanced heart failure requiring inotropic therapy or mechanical circulatory support [12].
