**10.1 Antiarrhythmic therapy**

Arrhythmias are common in patients hospitalized for PPCM. The occurrence of arterial and ventricular arrhythmias is variable. In one of the studies, 18.7% PPCM patients had an arrhythmia, and ventricular tachycardia was in 4.2% with cardiac arrest in 2.2%. In smaller studies, the reported incidence of ventricular tachycardia was 20 and 25%. The atrial fibrillation was reported to occur in 3.1–11.9% of patients with PPCM [23].

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these patients.

patients [26].

*Peripartum Cardiomyopathy: Facts and Figures DOI: http://dx.doi.org/10.5772/intechopen.85718*

**10.2 Anticoagulation therapy**

postpartum period warfarin is used.

functions to normal by 6 months to 5 years [25].

Ventricular arrhythmias should be treated aggressively in PPCM patients. Class III antiarrythmic medications are the best option. Intravenous medications are needed in PPCM patients admitted to the intensive care therapy unit. Therapy with inotropes such as dobutamine, adrenaline, and milrinone should be directed by invasive cardiac monitoring. While interpreting the invasive hemodynamic monitoring, one should take into account the normal changes that occur during pregnancy. Digoxin is safe to use in pregnancy. Diuretics can be used if salt restriction is not sufficient. Beta-blocker improves left ventricular function in patients of PPCM,

The anticoagulation in PPCM is a must as pregnancy itself is a hypercoagulable state, in addition to PPCM, dilatation of heart, and turbulent flow of blood. For pregnant patients requiring anticoagulation, decisions and choosing anticoagulation therapy are challenging due to the risk of bleeding in all stages of pregnancy and the potential teratogenic effects of warfarin in the first trimester, dosage of various agents, and management during labor and delivery. PPCM patients receiving bromocriptine have an increased risk of thromboembolic events; hence, it is suggested to start anticoagulation therapy in patients with PPCM treated with bromocriptine. There is no clear data, but expert suggests anticoagulation for patients with PPCM with acute cardiac thrombus or evidence of systemic embolism. Before delivery unfraction or low-molecular-weight heparin is the choice, whereas in

but ACE inhibitors are the drugs of choice in postpartum PPCM [24].

**10.3 Mechanical and device support and cardiac transplantation**

The decisions to use implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy in PPCM patients should be taken after a detailed natural history and the potential of recovery of ventricular function. All these therapies should be deferred at least for 3 months and possibly for 6 months of presentation as 20–60% of PPCM patients have complete recovery of left ventricular ejection

Mechanical circulatory support (MCS) is considered early for PPCM patients who are hemodynamically unstable and unresponsive to medical therapy with maximal inotropic support. A device can be implanted in the acute phase either to work as a bridge-to-recovery and subsequent weaning when the ventricular function improves, or it can be a bridge-to-bridge for implantation of a longer durable device. The bridge-to-transplantation is rarely required as the initial approach as a high proportion of PPCM patients will have recovery of ventricular function. Hence initially a temporary device should be used if required in

Severely reduced LVEF alone should not be an indication for the use of aggressive therapies (MCS and cardiac transplantation) in PPCM patients. If MCS is indicated, various devices can be used including intra-aortic balloon counterpulsation (IABP), venoarterial extracorporeal membrane oxygenation (ECMO), and LV assist device (LVAD). The choice of device will depend on the hemodynamic status of the patient and local availability and expertise. Venoarterial ECMO has been associated with an increase in prolactin levels, which may be detrimental in PPCM

Loyaga-Rendon et al. reported that the PPCM patients who received durable mechanical circulatory support had better survival rate than that of females

without PPCM with a survival rate of 83% in PPCM. These may be related to PPCM

*Peripartum Cardiomyopathy: Facts and Figures DOI: http://dx.doi.org/10.5772/intechopen.85718*

*Inflammatory Heart Diseases*

**10. Management**

**Figure 4.**

investigational medications (bromocriptine).

*Four chamber echocardiographic view showing thrombus in PPCM.*

prevention of thromboembolic events.

**10.1 Antiarrhythmic therapy**

patients with PPCM [23].

The therapeutic approach of PPCM is the same as for other types of HF with left ventricular systolic dysfunction. Precautions should be taken to ensure the safety of the mother and the unborn or breastfeeding child; these patients may need antiarrhythmic drugs, anticoagulation therapy, mechanical support, and the use of

The cornerstone in the management of PPCM is to reduce preload and after load and increase the cardiac contractility. Heart failure during pregnancy may be acute or acute on chronic. The pregnant patient with known cardiac disease can present in stable condition during early stages of pregnancy. Careful physical examination should be done. Their management is mainly adjustment of their medication and monitoring for cardiac failure. The initial New York Heart Association functional class status should be documented. Serial ECG and echocardiogram should be performed. Patients presenting heart failure during pregnancy or the peripartum period require a detail history and physical examination and the evaluation of severity of decompensation. An ECG may reveal deteriorating left ventricular functions, arrhythmia, LVH, or arterial abnormality. The therapeutic approach in these patients includes optimizing hemodynamics, reducing after load, optimizing preload, and cardiac contractility. These can be achieved by treatment of pulmonary congestion, control of hyper-/hypotension, treatment of cardiac arrhythmia, and

Arrhythmias are common in patients hospitalized for PPCM. The occurrence of arterial and ventricular arrhythmias is variable. In one of the studies, 18.7% PPCM patients had an arrhythmia, and ventricular tachycardia was in 4.2% with cardiac arrest in 2.2%. In smaller studies, the reported incidence of ventricular tachycardia was 20 and 25%. The atrial fibrillation was reported to occur in 3.1–11.9% of

**116**

Ventricular arrhythmias should be treated aggressively in PPCM patients. Class III antiarrythmic medications are the best option. Intravenous medications are needed in PPCM patients admitted to the intensive care therapy unit. Therapy with inotropes such as dobutamine, adrenaline, and milrinone should be directed by invasive cardiac monitoring. While interpreting the invasive hemodynamic monitoring, one should take into account the normal changes that occur during pregnancy. Digoxin is safe to use in pregnancy. Diuretics can be used if salt restriction is not sufficient. Beta-blocker improves left ventricular function in patients of PPCM, but ACE inhibitors are the drugs of choice in postpartum PPCM [24].

#### **10.2 Anticoagulation therapy**

The anticoagulation in PPCM is a must as pregnancy itself is a hypercoagulable state, in addition to PPCM, dilatation of heart, and turbulent flow of blood. For pregnant patients requiring anticoagulation, decisions and choosing anticoagulation therapy are challenging due to the risk of bleeding in all stages of pregnancy and the potential teratogenic effects of warfarin in the first trimester, dosage of various agents, and management during labor and delivery. PPCM patients receiving bromocriptine have an increased risk of thromboembolic events; hence, it is suggested to start anticoagulation therapy in patients with PPCM treated with bromocriptine. There is no clear data, but expert suggests anticoagulation for patients with PPCM with acute cardiac thrombus or evidence of systemic embolism. Before delivery unfraction or low-molecular-weight heparin is the choice, whereas in postpartum period warfarin is used.

#### **10.3 Mechanical and device support and cardiac transplantation**

The decisions to use implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy in PPCM patients should be taken after a detailed natural history and the potential of recovery of ventricular function. All these therapies should be deferred at least for 3 months and possibly for 6 months of presentation as 20–60% of PPCM patients have complete recovery of left ventricular ejection functions to normal by 6 months to 5 years [25].

Mechanical circulatory support (MCS) is considered early for PPCM patients who are hemodynamically unstable and unresponsive to medical therapy with maximal inotropic support. A device can be implanted in the acute phase either to work as a bridge-to-recovery and subsequent weaning when the ventricular function improves, or it can be a bridge-to-bridge for implantation of a longer durable device. The bridge-to-transplantation is rarely required as the initial approach as a high proportion of PPCM patients will have recovery of ventricular function. Hence initially a temporary device should be used if required in these patients.

Severely reduced LVEF alone should not be an indication for the use of aggressive therapies (MCS and cardiac transplantation) in PPCM patients. If MCS is indicated, various devices can be used including intra-aortic balloon counterpulsation (IABP), venoarterial extracorporeal membrane oxygenation (ECMO), and LV assist device (LVAD). The choice of device will depend on the hemodynamic status of the patient and local availability and expertise. Venoarterial ECMO has been associated with an increase in prolactin levels, which may be detrimental in PPCM patients [26].

Loyaga-Rendon et al. reported that the PPCM patients who received durable mechanical circulatory support had better survival rate than that of females without PPCM with a survival rate of 83% in PPCM. These may be related to PPCM

#### *Inflammatory Heart Diseases*

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 transplant facilities.

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].
