by, Julie Vasher, DNP, RNC-OB, CNS, C-EFM
Clinical Implementation Lead at the California Maternity Quality Care Collaborative at Stanford University
Janine is a 27-year-old African American woman who gave birth to her second baby without complications ten days ago. She came into the emergency room with complaints of cough and extreme tiredness. She attributes the fatigue to her new baby’s sleep schedule. She spoke in bursts because she appeared to be short of breath. Her vital signs are: blood pressure 120/60; heart rate 112 bpm; afebrile; respiratory rate 28 with an oxygen saturation of 94%; and she is considered obese (BMI 36). She has continued swelling in her feet. She is given antibiotics, steroids and breathing treatments. She feels better and is discharged home. A week later she returns to her physician with continued and worsening symptoms. The physician changes her antibiotic for an upper respiratory infection and suggests future testing for asthma. A few days later, the patient experiences cardiac arrest at home and resuscitative attempts are not successful. Autopsy findings indicate she died from cardiomyopathy. (A composite case study representative of several PPCM cases found online)
Women are entering pregnancy with more chronic disease like hypertension, diabetes, and obesity. (CDC). Cardiovascular disease (CVD) is the leading cause of death for women during pregnancy and the postpartum period (Hameed, Lawton, McCain et al., 2015). Peripartum cardiomyopathy (PPCM) is an unusual disorder occurring in pregnancy that causes the heart to dilate and weaken, leading to symptoms of heart failure.
Recent findings suggest both genetic and vascular factors play a significant role in development of PPCM (McNamara et al., 2015). Cardiomyopathy occurs infrequently in women of childbearing age, with a rate of 0.5-4% in developed countries, yet cardiomyopathy accounts for 11% of all maternal deaths in the United States (Lewey & Haythe, 2014). Additionally, many women experience short term and long term complications as a result of a delay of diagnosis or no diagnosis at all (Hameed, Lawton, McCain et al.).
Heart failure as a result of peripartum cardiomyopathy can occur in women, without previously diagnosed heart disease, during the last month of pregnancy up to five months postpartum. Various symptoms of cardiovascular disease mimic common symptoms found in pregnancy including fatigue, shortness of breath, and swelling.
Women can generally tolerate the hemodynamic changes of pregnancy, but those with undiagnosed cardiac disease can decompensate quickly (Simpson, 2012). A validated scoring tool is available for women and healthcare providers to distinguish between common, normal signs and symptoms of term pregnancy and those related to peripartum cardiomyopathy (Fett, 2011). The questions explore signs and symptoms such as orthopnea, dyspnea, unexplained cough, swelling, excessive weight gain and heart palpitations (Fett). It is important to review any signs and symptoms in context of the woman’s clinical physical assessment.
Risk factors for cardiovascular disease in pregnancy and peripartum cardiomyopathy:
Age – women over 30 years of age had higher incidence of CVD in pregnancy (Elkayam, Akhter, Singh, et al., 2005).
Race – African American women have an increased incidence of CVD in pregnancy compared to white women. The CVD pregnancy related mortality rate for African American women is more than EIGHT times higher than for white women (Hameed, Lawton, McCain et al., 2015)
Obesity – BMI >35 (Hameed, Lawton, McCain et al., 2015)
Diabetes – The increased rate of diabetes in the population as a whole, increases the incidence of all types of cardiovascular disease (Nickens, 2013).
- Gestational hypertension, chronic hypertension and preeclampsia had two-to-five-fold increase in odds of developing PPCM
- Preeclampsia with severe features had 17-fold risk and eclampsia 25-fold increase (Fong, Lovell, Gabby et al., 2014)
Multi-fetal gestation – Multiple gestation pregnancy has at least a two-fold risk for the development of PPCM (Elkayam, 2011)
Clinical Pearls for CVD in pregnancy:
- The first presentation of cardiovascular disease may be during pregnancy or the early postpartum period
- Pregnant or postpartum women presenting with symptoms of shortness of breath, cough or excessive fatigue should be evaluated in the context of risk factors, vital sign abnormalities and abnormal physical examination findings
- Patient education to improve awareness of risk factors, sign and symptoms of cardiac disease, and compliance with follow-up care should be emphasized
- A high index of suspicion and early diagnosis, along with appropriate referrals and follow-up are the key elements to a successful outcome
- Emergency Department (ED) providers, Primary Care Providers, and Obstetricians should maintain a high index of suspicion for underlying cardiovascular disease when a woman presents with symptoms, signs, and risk factors concerning for heart disease for as long five months postpartum
Julie contributed to the development of the Cardiovascular Disease in Pregnancy Toolkit as a member of the Cardiovascular Disease in Pregnancy Taskforce. Please visit at www.cmqcc.org.
For questions, please contact Julie at firstname.lastname@example.org
For more information and patient education materials:
Cardiovascular Disease Signs & Symptoms Infographic (English and Spanish) https://www.cmqcc.org/resources-tool-kits/infographics
Cardiovascular Disease Lifetime Risks Infographic (English and Spanish) https://www.cmqcc.org/resources-tool-kits/infographics
CMQCC will soon release a Cardiovascular Disease in Pregnancy Toolkit. When released, it will be available at www.cmqcc.org
Hameed A, Lawton E, McCain C, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008.
Elkayam, U. (2011). Clinical characteristics of peripartum cardiomyopathy in the United States. Journal of the American College of Cardiology, 58, 7.
Elkayam, U., Akhter, M., Singh, H., Khan, S., Bita, F., Hameed, A., & Shotan, A. (2005). Pregnancy-associated cardiomyopathy: Clinical characteristics and a comparison between early and late presentation. Circulation, doi: 10.1161/01.CIR.0000162478.36652.7E.
Fett, J. (2011). Validation of a self-test for early diagnosis of heart failure in peripartum cardiomyopathy. Crit Pathw Cardiol. 10:44-5.
Fong A, Lovell S, Gabby L, Pan D, Ogunyemi D, Hameed A. (2014). Peripartum cardiomyopathy: Demographics, antenatal factors, and a strong association with hypertensive disorders. American Journal of Obstetrics and Gynecology. 210(1, Supplement):S136.
Lewey, J., & Haythe, J. (2014). Cardiomyopathy in pregnancy. Seminars in Perinatology, 38, 309-317.
McNamara, D., Elkayam, U., Alharethi, R., Damp, J., Hsich, E., Ewald, G., Modi, K., Alexic, J., Ramani, G., Semigran, M., Haythe, J., Markham, D., Marek, J., Gorscan, J., Wu, W., Lin, Y., Halder, I., Pisarcik, J., Cooper, L., & Fett, J. (2015). Clinical outcomes for peripartum cardiomyopathy in North America. Journal of the American College of Cardiology, 66, 8.
Nickens, M., Long, R., & Geraci, S. (2013). Cardiovascular disease in pregnancy. Southern Medical Association, 106,11.
Simpson, L. (2012). Maternal cardiac disease: Update for the clinician. Obstetrics & Gynecology, 119, 2 part 1.