Patient handout

Peripartum Cardiomyopathy (PPCM)

PRODUCTION

1. Your condition

This handout is for peripartum cardiomyopathy (ppcm). Your care team identified this based on: new dyspnea / orthopnea / paroxysmal nocturnal dyspnea in last month of pregnancy through 5 months postpartum (pearson 2000 nhlbi; esc hf 2021 pmid 34447992).

Other reasons your team may use this plan: new / progressive lower-extremity edema disproportionate to expected pregnancy / postpartum baseline (esc hf 2021); transthoracic echocardiogram showing ef < 45 % in peripartum window with no other identifiable cause (pearson 2000 nhlbi); sbp < 90 + end-organ hypoperfusion in peripartum patient (esc hf 2021; cardio.cardiogenic-shock.core.v1 overlay).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
hydralazine	10–25 mg PO TID-QID; titrate to 25–100 mg PO QID (max ~ 300 mg/day); IV 5–10 mg q20min for acute severe HTN	PO / IV	TID-QID	ESC Pregnancy 2018 — pregnancy-safe arterial vasodilator; combine with nitrates for afterload + preload reduction; ACEi/ARB/ARNI/renin inhibitor contraindicated antepartum (fetal renal dysplasia / oligohydramnios / neonatal hypotension)
isosorbide dinitrate	10–20 mg PO TID; titrate to 40 mg PO TID (allow nitrate-free interval); IV nitroglycerin 5–20 mcg/min titrated for acute pulmonary edema	PO / IV	TID	ESC Pregnancy 2018 — pregnancy-safe venodilator; combined with hydralazine substitutes for ACEi/ARB in pregnancy (V-HeFT vintage regimen + A-HeFT in African-American HFrEF cohort)
carvedilol	3.125 mg PO BID; titrate q2 wk to 25 mg PO BID (or 50 mg BID if > 85 kg); HOLD if SBP < 90 or HR < 55	PO	BID	AHA/ACC/HFSA 2022 + ESC HF 2021 — first-line beta-blocker for HFrEF; pregnancy-acceptable per ESC Pregnancy 2018 (avoid atenolol due to FGR risk per NICE 2019)
metoprolol succinate	12.5–25 mg PO daily; titrate q2 wk to 200 mg PO daily; HOLD if SBP < 90 or HR < 55	PO	daily	AHA/ACC/HFSA 2022 + ESC HF 2021 — first-line beta-blocker for HFrEF; pregnancy-acceptable; lactation-compatible (low transfer)
bisoprolol	1.25 mg PO daily; titrate q2 wk to 10 mg PO daily; HOLD if SBP < 90 or HR < 55	PO	daily	ESC HF 2021 — alternative cardioselective beta-blocker; pregnancy-acceptable per ESC Pregnancy 2018
furosemide	20–40 mg PO/IV BID; titrate to symptomatic euvolemia; cautious dosing antepartum to avoid placental hypoperfusion	PO / IV	BID-TID	ESC HF 2021 + AHA/ACC/HFSA 2022 — preferred loop diuretic in pregnancy and lactation; cautious antepartum dosing per ESC Pregnancy 2018

Plan: Peripartum cardiomyopathy — timing-tier-and-severity-driven (antepartum pregnancy-safe regimen → intrapartum hemodynamic management → postpartum full GDMT; anticoagulation + bromocriptine consideration + wearable defibrillator / ICD per severity tier)

3. When to call your provider

Contact your care team if any of the following happen:

Worsening NYHA class or symptoms → urgent cardiology + echo + natural marker of fluid overload (NT-proBNP)
EF declines on serial echo → uptitrate the four foundational heart-failure medications + consider MCS evaluation + advanced HF referral
New LV thrombus on echo → therapeutic anticoagulation
New AFib or sustained ventricular arrhythmia → cardiology / EP + anticoagulation review
EF persistently < 35 % after ≥ 6 mo optimal the four foundational heart-failure medications → ICD evaluation (AHA HF 2022 class I)
No EF recovery at 12 mo → advanced HF + transplant evaluation
Postpartum severe HTN ≥ 160/110 within 6 wk → ED for IV antihypertensive + magnesium prophylaxis (AHA 2021 + ACOG 222)
Subsequent pregnancy planning → preconception MFM + cardiology consultation; advise against pregnancy if EF not recovered per shared decision

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Antepartum PPCM with cardiogenic shock (SBP < 90 + end-organ hypoperfusion + rising lactate + oliguria) → emergent delivery + ICU + mechanical circulatory support consideration (IABP / Impella / ECMO / VAD); cardiothoracic + OB + anesthesia + neonatology team; ECMO during delivery if needed (ESC HF 2021 PMID 34447992 + ESC Pregnancy 2018 PMID 30165544)(life-threatening)
PPCM with severe LV dysfunction (EF < 35 %) — bridge medical therapy + wearable cardioverter-defibrillator (LifeVest) consideration during first 3–6 mo of the four foundational heart-failure medications + cardiology + monitor for recovery × 6 mo before ICD evaluation (AHA/ACC/HFSA 2022 PMID 35379503)
PPCM with LV mural thrombus on transthoracic or transesophageal echocardiography → therapeutic anticoagulation (warfarin postpartum / LMWH antepartum; DOACs off-label for non-valvular cardioembolic per shared decision); serial echo q4–6 wk to monitor resolution (ESC HF 2021 PMID 34447992)(life-threatening)
PPCM with sustained VT / VF or other malignant ventricular arrhythmia → antiarrhythmics (amiodarone — postpartum first; lidocaine acceptable antepartum) + wearable cardioverter-defibrillator + EP consult; risk-stratify for ICD if persistent low EF after 6 mo optimal medical therapy (AHA/ACC/HFSA 2022 PMID 35379503)(life-threatening)
Antepartum PPCM with decompensated pulmonary edema (oxygen level (SpO₂) < 94 % + bilateral crackles + tachypnea + dyspnea on minimal exertion) → IV diuretics + nitrates (if BP permits) + early-delivery consideration; routes to OB / MFM for delivery planning + anesthesia for hemodynamic management; CAUTIOUS diuresis to avoid placental hypoperfusion (ESC HF 2021 + ESC Pregnancy 2018 PMID 30165544)(life-threatening)
PPCM with concurrent pre-eclampsia (severe features) or HELLP syndrome → combined management; pre-eclampsia management drives delivery decision (ACOG 222); cardiology coordinates HF medications avoiding teratogenic combinations; magnesium for pre-eclampsia severe features still indicated but monitor for synergistic hypotension with afterload reduction in PPCM (ESC Pregnancy 2018 + ACOG 222 + Magpie 2002 PMID 12057549)
Subsequent pregnancy planning after prior PPCM → preconception MFM + cardiology consultation; recurrence 30–50 % if EF not fully recovered (≥ 50 %); 15–20 % if EF recovered; baseline echo + natural marker of fluid overload (NT-proBNP) + stress test; close surveillance from first trimester; some specialists advise against pregnancy if EF not recovered (ESC Pregnancy 2018 PMID 30165544; ESC HF 2021 PMID 34447992)
PPCM with EF persistently < 35 % at 12 mo despite optimal the four foundational heart-failure medications (maximum tolerated ACEi/ARNI + beta-blocker + MRA + SGLT2i + lifestyle) → advanced HF evaluation including transplant referral + VAD evaluation + ICD; pregnancy contraindication counseling; advanced HF center referral if not already (AHA/ACC/HFSA 2022 PMID 35379503 + ESC HF 2021 PMID 34447992)

5. Follow-up

Cardiology q3 mo × 12 mo + thereafter q6 mo if recovered; serial echocardiography q3 mo × 12 mo (or sooner if worsening); the four foundational heart-failure medications uptitration to maximum tolerated; ICD evaluation only after ≥ 6 mo optimal medical therapy if EF persistently < 35 % per AHA/ACC/HFSA 2022 PMID 35379503; advanced HF / transplant referral if no recovery at 12 mo; preconception MFM + cardiology consultation if planning next pregnancy with recurrence-risk counseling (30–50 % if EF not recovered, 15–20 % if recovered); highly-effective contraception during recovery (IUD, etonogestrel implant; avoid combined estrogen contraceptives in EF < 50 % per WHO MEC); EPDS / PPD screen + perinatal mental health referral as needed (psych.postpartum-depression.v1 overlay); psychosocial + family counseling

6. Sources

Guideline: ESC Heart Failure 2021 (McDonagh et al, Eur Heart J 2021) + AHA/ACC/HFSA Heart Failure 2022 (Heidenreich et al, JACC 2022) + ESC Pregnancy 2018 (Regitz-Zagrosek et al, Eur Heart J 2018) + IPAC trial 2015 (McNamara et al, JACC 2015) + Hilfiker-Kleiner 2018 Eur Heart J bromocriptine multicentre randomized + EURObservational PPCM Registry (Sliwa et al, Eur Heart J 2020) + Pearson 2000 NHLBI diagnostic criteria + ACOG 222 (2020, reaff 2024) + ACOG 767 (2017, reaff 2020) + ACOG 713 antenatal corticosteroids (2017) + Roberts Cochrane antenatal steroids 2017 + Liggins 1972 + DAPA-HF NEJM 2019 + EMPEROR-Reduced NEJM 2020 + Magpie Lancet 2002 + WHO MEC contraception