Pregnant again after peripartum cardiomyopathy: to be or not to be?

Peripartum cardiomyopathy is a form of heart failure caused by depression of left ventricular systolic function that occurs in healthy women during pregnancy or within a few months postpartum and can have devastating consequences, both physically and mentally. Although this condition may deteriorate and result in a need for heart transplantation or even death, the majority of patients demonstrate a significant recovery of symptoms and cardiac function within a few months after delivery. One of the most common issues for women surviving an episode of peripartum cardiomyopathy is whether it is safe to become pregnant again. Because of the rarity of this condition (approximately 1:10 000 deliveries in the United States), reports on peripartum cardiomyopathy have been limited to either single cases or a small number of patients. For this reason, it is not surprising that a position paper published in 2000 following a National Heart, Lung and Blood Institute workshop on peripartum cardiomyopathy in 1997, could not provide a consensus regarding recommendations for future pregnancy after peripartum cardiomyopathy. We recently conducted a survey among the members of the American College of Cardiology in the United States and one hospital in South Africa and were able to determine the outcome of 60 subsequent pregnancies in 44 women with a history of peripartum cardiomyopathy. Twenty-eight of these patients normalized their left ventricular systolic function prior to their additional pregnancy (group 1), and 16 women had persistent left ventricular dysfunction (group 2). First subsequent pregnancy was associated with a significant decrease in left ventricular ejection fraction, which was seen, in the study population as a whole as well as in each group (Fig. 1). During the first subsequent pregnancy, 21% of group 1 women and 44% of group 2 women developed symptoms of heart failure (Fig. 2). Twenty-one percent of group 1 and 25% of group 2 had a >20% decrease in left ventricular ejection fraction either during their subsequent pregnancy or during the early postpartum period. Decreased cardiac function either persisted or developed late and