A 32-year-old woman, gravida 1 para 1, comes to the office for preconceptual counseling. A year ago, the patient's pregnancy was complicated by congestive heart failure diagnosed at 36 weeks gestation when she developed fatigue and shortness of breath. Evaluation at that time revealed a left ventricular ejection fraction of 20%. The patient subsequently underwent a preterm induction of labor and had a vaginal delivery. She was started on carvedilol and lisinopril, which she continues to take without side effects. A follow-up echocardiogram at 6 months postpartum showed an improving ejection fraction. The patient tolerates daily activities and has no chest pain, shortness of breath, syncope, or lower extremity swelling. She has no other chronic medical conditions and has had no surgeries. The patient does not use tobacco, alcohol, or illicit drugs. She is considering another pregnancy and would like an assessment of her risk. Which of the following provides the best prognostic information regarding this patient's risk during a future pregnancy?

Question

A 32-year-old woman, gravida 1 para 1, comes to the office for preconceptual counseling.  A year ago, the patient's pregnancy was complicated by congestive heart failure diagnosed at 36 weeks gestation when she developed fatigue and shortness of breath.  Evaluation at that time revealed a left ventricular ejection fraction of 20%.  The patient subsequently underwent a preterm induction of labor and had a vaginal delivery.  She was started on carvedilol and lisinopril, which she continues to take without side effects.  A follow-up echocardiogram at 6 months postpartum showed an improving ejection fraction.  The patient tolerates daily activities and has no chest pain, shortness of breath, syncope, or lower extremity swelling.  She has no other chronic medical conditions and has had no surgeries.  The patient does not use tobacco, alcohol, or illicit drugs.  She is considering another pregnancy and would like an assessment of her risk.  Which of the following provides the best prognostic information regarding this patient's risk during a future pregnancy?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c118_efa6_8f63_c32b201133c4_MD0005_00 Peripartum cardiomyopathy (PPCM) is heart failure that occurs between 36 weeks gestation and 5 months postpartum. Risk factors include maternal age >30, multiple gestation, and preeclampsia. Patients present with left heart failure symptoms (eg, dyspnea), left ventricular ejection fraction (LVEF) <45%, and no other cause of heart failure (ie, diagnosis of exclusion). Management of PPCM is similar to that of other causes of systolic heart failure. Patients who develop PPCM during pregnancy are delivered based on maternal stability. After delivery: Some patients will have spontaneous resolution of ventricular dysfunction and can discontinue their medication regimen; however, there is a risk of recurrence, with patients with LVEF <20% at diagnosis at highest risk. Patients with persistent PPCM are at risk for further LV function decline and death in subsequent pregnancies. Therefore, regardless of PPCM resolution, patients are evaluated with serial echocardiograms for a few years (Choice D). Those with recurrent or persistent LV dysfunction are advised to avoid pregnancy. (Choice A) Ambulatory blood pressure monitoring can detect the presence of hypertension that increases the risk of preeclampsia in future pregnancy. Although hypertension is a risk factor for peripartum cardiomyopathy, it does not predict recurrence. (Choice B) Brain natriuretic peptide levels are elevated in patients with heart failure, and serial measurement can be helpful in patients at risk of developing heart failure during pregnancy. However, brain natriuretic peptide levels do not clarify the risk of peripartum cardiomyopathy recurrence. (Choice C) The exercise electrocardiogram test is indicated in the assessment of coronary artery disease and the determination of functional capacity. It does not predict the risk of recurrence in patients with prior peripartum cardiomyopathy. Educational objective: Patients with a history of peripartum cardiomyopathy are at risk of recurrence, further left ventricular (LV) function decline, and death in subsequent pregnancies. The risk is stratified based on LV function at diagnosis and current LV function as assessed by transthoracic echocardiogram. References: Peripartum cardiomyopathy: current state of knowledge, new developments and future directions. (http://www.ncbi.nlm.nih.gov/pubmed/24646160) Peripartum cardiomyopathy: a contemporary review. (http://www.ncbi.nlm.nih.gov/pubmed/23519269) Maternal and fetal outcomes of subsequent pregnancies in women with peripartum cardiomyopathy. (http://www.ncbi.nlm.nih.gov/pubmed/11372007)

A 32-Year-Old Woman, Gravida 1 Para 1, Comes to the Office