TY  - CHAP
M1  - Book, Section
TI  - Cardiovascular Complications of Pregnancy
A1  - Bashore, Thomas M.
A1  - Granger, Christopher B.
A1  - Jackson, Kevin P.
A1  - Patel, Manesh R.
A2  - Papadakis, Maxine A.
A2  - McPhee, Stephen J.
A2  - Rabow, Michael W.
A2  - McQuaid, Kenneth R.
PY  - 2022
T2  - Current Medical Diagnosis & Treatment 2022
AB  - In  approximately  1  in  3000  to  4000  live  births,  dilated  cardiomyopathy  develops  in  the  mother  in  the  final  month  of  pregnancy  or  within  6  months  after  delivery.  Risk  factors  include  preeclampsia,  twin  pregnancies,  and  African  ethnicity.  The  cause  is  slowly  being  elucidated.  The  vasculo-hormonal  hypothesis  requires  two  events.  One  is  genetic,  a  reduction  in  a  STAT3  transcription  factor  that  results  in  cleavage  of  prolactin  from  the  pituitary  by  cathepsin  D.  This  results  in  a  16-kd  fragment  that  increases  microRNA  146a  that  results  in  myocardial  apoptosis.  The  second  is  from  the  placenta,  soluble  tyrosine  kinase  that  blocks  VEGF  (vascular  endothelial  growth  factor).  It  appears  both  components  may  be  necessary  to  effectively  result  in  peripartum  cardiomyopathy.  The  course  of  the  disease  is  variable;  most  cases  improve  or  resolve  completely  over  several  months,  but  others  progress  to  refractory  heart  failure.  About  60%  of  patients  make  a  complete  recovery.  Serum  BNP  levels  are  routinely  elevated  in  pregnancy,  but  serial  values  may  be  useful  in  predicting  who  may  be  at  increased  risk  for  a  worse  outcome.  Beta-blockers  have  been  administered  judiciously  to  these  patients,  with  at  least  anecdotal  success.  Diuretics,  hydralazine,  and  nitrates  help  treat  the  heart  failure  with  minimal  risk  to  the  fetus.  Sotalol  is  acceptable  for  ventricular  or  atrial  arrhythmias  if  other  beta-blockers  are  ineffective.  Some  experts  advocate  anticoagulation  because  of  an  increased  risk  of  thrombotic  events,  and  both  warfarin  and  heparin  have  their  proponents.  In  severe  cases,  transient  use  of  extracorporeal  membrane  oxygenation  (ECMO)  has  been  lifesaving.  Recurrence  in  subsequent  pregnancies  is  common,  particularly  if  cardiac  function  has  not  completely  recovered,  and  subsequent  pregnancies  are  to  be  discouraged  if  the  EF  remains  less  than  55%.  The  risk  of  recurrent  heart  failure  in  a  subsequent  pregnancy  has  been  estimated  to  be  21%.  Delivery  of  the  baby  is  important,  though  the  peak  incidence  of  the  problem  is  in  the  first  week  after  delivery  and  a  few  cases  appear  up  to  5  weeks  after  delivery.  Since  the  anti-angiogenic  cleaved  prolactin  fragment  is  considered  causal  for  peripartum  cardiomyopathy,  bromocriptine  (a  prolactin  release  inhibitor)  has  been  reported  to  be  beneficial.  A  multicenter  trial  in  Europe  found  LVEF  improved  to  a  greater  extent  in  patients  with  peripartum  cardiomyopathy  who  were  given  bromocriptine  than  those  who  were  not  given  bromocriptine.  In  addition,  bromocriptine  treatment  was  associated  with  high  rate  of  full  LV  recovery  and  low  morbidity  and  mortality  in  peripartum  cardiomyopathy  patients  compared  with  other  peripartum  cardiomyopathy  cohorts  not  treated  with  bromocriptine.  
SN  - 
PB  - McGraw-Hill Education
CY  - New York, NY
Y2  - 2024/04/16
UR  - accessmedicine.mhmedical.com/content.aspx?aid=1184696642
ER  -