A 29-year-old woman comes to the physician accompanied by her husband for an initial consultation. She has no current symptoms. She is physically active and walks for 45 minutes on a treadmill 3-4 days a week. She has a past history of "heart failure," which was diagnosed 1 week after the birth of her first child 2 years ago.
She was found to have a reduced LV ejection fraction of 25%, but further evaluation did not reveal any specific cause of her cardiomyopathy. She has been taking daily furosemide, potassium supplements, carvedilol, and quinapril since that time. Her last echocardiogram 2 months ago showed an improved LV ejection fraction of 40%, mild left atrial enlargement, and mild mitral regurgitation. The couple is contemplating another pregnancy and was referred by the obstetrician for a second opinion.
Which of the following is the most appropriate recommendation?

Question

A 29-year-old woman comes to the physician accompanied by her husband for an initial consultation.  She has no current symptoms.  She is physically active and walks for 45 minutes on a treadmill 3-4 days a week.  She has a past history of "heart failure," which was diagnosed 1 week after the birth of her first child 2 years ago.
She was found to have a reduced LV ejection fraction of 25%, but further evaluation did not reveal any specific cause of her cardiomyopathy.  She has been taking daily furosemide, potassium supplements, carvedilol, and quinapril since that time.  Her last echocardiogram 2 months ago showed an improved LV ejection fraction of 40%, mild left atrial enlargement, and mild mitral regurgitation.  The couple is contemplating another pregnancy and was referred by the obstetrician for a second opinion.
Which of the following is the most appropriate recommendation?

Quizplus · Accepted Answer

11ec193a_9744_0ec1_853d_817d607a8f72_MD0002_00 This patient's history is consistent with peripartum cardiomyopathy (PPCM), an uncommon cause of heart failure. The etiology is unknown but may be multifactorial (e.g., immune-mediated, myocarditis, etc.). Risk factors for PPCM include age > 30, multiparity, African descent, pregnancy with multiple fetuses, maternal cocaine use, and beta-agonist (e.g., terbutaline) use > 4 weeks. Patients typically present with heart failure symptoms (usually dyspnea) and are diagnosed based on clinical criteria and an echocardiogram. Peripartum cardiomyopathy treatment is similar to usual heart failure therapy, but ACE inhibitors and ARBs are teratogenic and should not be taken during pregnancy (Choice B). Diuretics relieve pulmonary congestion, but loop diuretics are preferred over thiazide diuretics due to increased risk of fetal bleeding diathesis. Beta-1 selective blockers are generally preferred due to decreased risk of uterine relaxation and peripheral vasodilation. Digoxin is only considered in symptomatic patients who fail first-line therapies. One major predictor of persistent LV dysfunction is LV ejection fraction (EF) < 30% at the time of diagnosis. Patients who recover LV function to normal have a lower risk of complications during subsequent pregnancies, but their risk is still elevated when compared to the general population. Patients with persistent LV dysfunction have a substantially higher risk of complications such as significant decline in LVEF, recurrent heart failure, and death and should avoid subsequent pregnancies. This patient is stable but still has a depressed LVEF. She should avoid pregnancy and continue her present medications (Choices C, D, and E). Educational objective: Patients with a history of peripartum cardiomyopathy and persistent LV dysfunction have a high risk of further decline in LV function, recurrent heart failure, and death with subsequent pregnancies. Such patients should be advised to avoid future pregnancy. __________ References: Maternal and fetal outcomes of subsequent pregnancies in women with peripartum cardiomyopathy (http://www.ncbi.nlm.nih.gov/pubmed/11372007) Peripartum cardiomyopathy: review and practice guidelines (http://www.ncbi.nlm.nih.gov/pubmed/22381985)

A 29-Year-Old Woman Comes to the Physician Accompanied by Her