Understanding Peripartum Cardiomyopathy: Causes, Symptoms, Treatment and Prevention

Peripartum cardiomyopathy (PPCM) is a rare form of heart failure that can affect a woman during the last trimester of pregnancy or within several months after giving birth. An obstetric emergency, PPCM affects pregnant women and recent mothers with no prior history of cardiovascular disease. Instead, the heart muscle abruptly weakens for no apparent reason, reducing the amount of blood pumped with each heartbeat. As a result, the heart may be unable to meet the body’s demands for oxygen, potentially disrupting the function of vital organs.

With an early diagnosis and appropriate treatment, it is often possible to restore heart function after peripartum cardiomyopathy. However, the condition can be challenging to recognize because many of its symptoms—including fatigue, ankle swelling and breathlessness—overlap with those of a normal pregnancy. By learning about PPCM, taking proactive steps to monitor heart health and promptly discussing any concerns with a physician, an expectant mother can ensure a safer pregnancy and postpartum recovery.

What Are the Types of Peripartum Cardiomyopathy?

PPCM is primarily defined as a single condition. Based on its presentation and progression, however, it may be categorized as:

• Mild PPCM – Minor symptoms may develop, such as tiredness and breathing discomfort, but heart function remains near normal. With proper treatment, full recovery is likely.
• Severe PPCM with reduced ejection fraction (EF) – Heart function is significantly weakened (low EF), resulting in heart failure symptoms, such as fluid retention, difficulty breathing and irregular heart rhythms (arrhythmias). Recovery can be prolonged, and some patients may require long-term treatment.
• PPCM with cardiogenic shock – The severely weakened heart cannot pump enough blood to vital organs throughout the body, leading to shock and necessitating advanced treatment, such as mechanical circulatory support or heart transplantation.
• Recurrent or chronic PPCM – Some women do not fully recover their heart function after peripartum cardiomyopathy. To help prevent complications, long-term cardiomyopathy may require lifelong monitoring and management.
• PPCM with thromboembolic complications – A weakened heart increases the risk of blood clots, which can lead to pulmonary embolism or stroke. Therefore, anticoagulant therapy may be required.

What Causes Peripartum Cardiomyopathy and What Are the Risk Factors?

The exact cause of PPCM is not fully understood. Researchers believe it likely results from a combination of genetic, hormonal, inflammatory and vascular issues, which collectively weaken the heart muscle during late pregnancy or postpartum. Potential contributing factors include:

• Genetics – PPCM runs in some families, suggesting a genetic predisposition.
• Hormonal fluctuations – High levels of pregnancy-related hormones, such as prolactin, may damage the vascular system.
• Increased inflammation – During pregnancy, immune cells actively invade the lining of the uterus to allow the developing embryo to implant, creating an inflammatory cascade similar to wound healing.
• Oxidative stress – To meet the increasing metabolic demands of the growing fetus, the placenta may produce high levels of reactive oxygen species (ROS), exceeding the body’s natural ability to neutralize ROS with antioxidants. The resulting imbalance between the production and accumulation of ROS may damage cells and tissues.
• Vascular abnormalities – Damaged or dysfunctional blood vessels can reduce blood flow to the heart, which may play a role in the development of peripartum cardiomyopathy.

While peripartum cardiomyopathy can affect any pregnant woman or recent mother, certain factors may increase the risk, including:

• Advanced maternal age – The risk of PPCM can increase with age, especially after 35. However, the condition can affect women of all ages.
• History of PPCM – Women who developed peripartum cardiomyopathy during a previous pregnancy are at risk of recurrence.
• Metabolic disorders – Conditions such as gestational diabetes and pre-existing diabetes can increase the risk of peripartum cardiomyopathy.
• Multiple pregnancies – Carrying two or more fetuses at a time can further stress the heart.
• Obesity – Carrying excess body weight can strain the cardiovascular system and may contribute to heart dysfunction.
• Preeclampsia and hypertension – High blood pressure, especially due to preeclampsia or gestational hypertension, can significantly increase the likelihood of postpartum cardiomyopathy.
• Prolonged or difficult labor – Increased stress on the cardiovascular system during delivery may contribute to heart muscle weakening.
• Use of tocolytic medications – Some studies show that certain drugs prescribed to delay preterm labor, such as beta-agonists, may increase the risk of PPCM.

What Are the Warning Signs and Symptoms of Peripartum Cardiomyopathy?

PPCM symptoms can be subtle, often resembling normal pregnancy-related changes. This can make early detection challenging. However, any persistent or worsening symptoms could signal heart dysfunction and should not be ignored.

Warning signs of peripartum cardiomyopathy can include:

• Chest pain – Whether mild or severe, any chest discomfort could indicate heart strain.
• Coughing – Fluid buildup in the lungs may trigger a persistent cough that produces pink or frothy sputum.
• Dizziness or fainting – Reduced blood flow to the brain may cause lightheadedness or fainting episodes.
• Fatigue – PPCM is often accompanied by unusual or extreme tiredness that does not improve with rest.
• Rapid or irregular heartbeat (palpitations) – Some patients experience the sensation of a racing, fluttering or pounding heart.
• Shortness of breath (dyspnea) – Difficulty breathing may occur, even with minimal exertion or when lying down.
• Sudden weight gain – Water retention may cause a rapid increase in body weight.
• Swelling (edema) – Fluid may accumulate in the legs, ankles, feet or abdomen.

How Is Peripartum Cardiomyopathy Diagnosed?

After reviewing the patient’s symptoms, medical history and risk factors, the physician will typically perform a physical examination to check for signs of heart failure, such as rapid heart rate (tachycardia), abnormal heart sounds, distended neck veins, crackling sounds during inhalation, swollen ankles and liver enlargement. If the physician suspects peripartum cardiomyopathy based on the results of the clinical assessment, they may order one or more medical tests to confirm the diagnosis and assess the severity of the related heart dysfunction. Options include:

• Echocardiogram – A key diagnostic tool that uses ultrasound to measure how well the heart pumps blood, an echocardiogram can help the physician evaluate the heart’s structure, function and EF. A reduced EF (typically <45%) suggests PPCM.
• Electrocardiogram (ECG/EKG) – An EKG records the heart’s electrical activity, which can help the physician detect irregular heart rhythms and other signs of heart strain.
• B-type natriuretic peptide (BNP) test – BNP is a hormone produced by the heart muscle to lower blood pressure by signaling the blood vessels to widen and the kidneys to excrete more salt and water through urine. As a result, the workload on the heart is reduced. BNP levels typically increase dramatically when the heart is under stress, a hallmark sign of heart failure.
• Chest X-ray – This imaging test, which uses radiation to create pictures of the heart, lungs, blood vessels, airways and bones in the chest and spine, can help the physician identify signs of heart enlargement and fluid buildup in the lungs.
• Cardiac magnetic resonance imaging (MRI) – Using radio waves and a strong magnetic field, MRI can produce detailed images of the heart to help the physician assess muscle damage, scarring and inflammation.
• Cardiac catheterization and angiography – This minimally invasive procedure uses a thin tube (catheter) and contrast dye to help the physician visualize the heart’s blood vessels and assess blood flow. This can help the physician rule out other causes of heart failure, such as coronary artery disease.

How Is Peripartum Cardiomyopathy Treated?

PPCM treatment focuses on improving heart function, managing symptoms and preventing complications, such as arrhythmias and blood clots. The specifics of the treatment plan can vary depending on the severity of the condition. Many patients benefit from medications and lifestyle adjustments, although severe cases may require more advanced therapies.

To address peripartum cardiomyopathy and improve heart function, a physician may prescribe:

• Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) – Can lower blood pressure and help the heart pump more efficiently (not typically used during pregnancy but may be started postpartum)
• Anticoagulants (blood thinners) – Can help prevent blood clots, a potential complication of severely reduced heart function
• Beta-blockers – Can slow the heart rate and lower blood pressure
• Diuretics – Can reduce fluid buildup to ease swelling and improve breathing
• Vasodilators – Can relax blood vessels and improve circulation

In general, a heart-healthy lifestyle for a woman with PPCM may include:

• Consuming a low-sodium diet – Can help manage blood pressure and fluid retention
• Maintaining a healthy body weight – Can prevent further strain on the heart
• Performing light to moderate physical activities – Can boost blood circulation and strengthen the heart muscle, although excessive exertion should be avoided during pregnancy

To address severe heart failure, advanced treatments may be considered, such as:

• Implantable cardioverter-defibrillator (ICD) – Can control arrhythmias by delivering shocks to the heart
• Mechanical circulatory support – Can help the heart pump blood throughout the body
• Heart transplant – Can replace the patient’s damaged heart with a healthy donor heart

What Are the Possible Complications and Long-Term Effects of Peripartum Cardiomyopathy?

PPCM can lead to serious complications if the condition is left untreated or if the patient’s heart function does not improve with treatment. The severity of its long-term effects can vary; some women experience full recovery while others develop chronic heart conditions.

Possible complications of peripartum cardiomyopathy include:

• Arrhythmias – Irregular heart rhythms, some of which may be life-threatening
• Blood clots – Semi-solid masses of blood cells that clump together due to poor circulation, which may cause a stroke
• Cardiogenic shock – Organ failure due to oxygen deprivation
• Congestive heart failure – A lifelong condition in which the heart cannot pump enough blood to meet the body’s needs
• Pulmonary edema – Fluid buildup in the lungs

Long-term effects of peripartum cardiomyopathy can include:

• Chronic heart dysfunction – Persistent weakening of the heart muscle and diminished heart capacity
• Increased risk in future pregnancies – Susceptibility to PPCM recurrence due to heart dysfunction
• Need for long-term cardiac care – Ongoing medications, lifestyle changes and routine monitoring to help prevent complications
• Reduced EF – A permanent decrease in ejection fraction, requiring lifelong management

How Can Peripartum Cardiomyopathy Be Prevented?

While PPCM cannot always be prevented, certain steps can be taken to help reduce the risk, especially in women with known risk factors. Proactive heart health management before, during and after pregnancy is key to minimizing the likelihood of developing PPCM. Strategies include:

• Avoiding tobacco use and alcohol consumption
• Consulting a cardiologist before planning future pregnancies
• Consuming a balanced diet
• Controlling hypertension and managing blood pressure
• Exercising regularly (with a physician’s oversight)
• Maintaining a healthy body weight
• Monitoring and treating pregnancy complications linked to PPCM, such as preeclampsia and gestational hypertension
• Monitoring PPCM symptoms and seeking medical attention when needed
• Receiving routine prenatal checkups and care
• Using effective contraception to avoid unintended pregnancies

Living With Peripartum Cardiomyopathy

Life after PPCM can vary depending on the severity of the condition and how well the heart recovers. Some women regain full heart function within a few months, while others experience long-term heart failure and require ongoing management. Daily life may involve taking medications, maintaining a heart-healthy lifestyle and attending regular medical checkups to monitor heart function. Lingering symptoms, such as fatigue, shortness of breath and fluid retention can impact day-to-day activities, especially in severe cases. Women with PPCM may also face emotional challenges, including anxiety about their health and future pregnancies. However, with proper treatment and lifestyle adjustments, many women can manage peripartum cardiomyopathy effectively and maintain a good quality of life.

Benefit From World-Class Care at TGH

If peripartum cardiomyopathy is suspected, it is essential to work closely with a healthcare provider who is experienced in managing female-specific cardiovascular conditions. With an early diagnosis and appropriate treatment, many women experience improved heart function and lead healthy lives. With that said, long-term management and monitoring are sometimes necessary.

Tampa General Hospital’s Heart and Vascular Institute features a Women’s Heart Program as well as a Cardio-Obstetrics Program. Our cardiac specialists are experts in identifying, preventing and treating heart conditions that solely or disproportionately affect females, including peripartum cardiomyopathy, Takotsubo cardiomyopathy and dilated cardiomyopathy.

TGH is the only hospital in the Tampa Bay region to be included in the list of “100 hospitals and health systems with great heart programs” compiled by Becker’s Hospital Review in 2023, and we are proud to have established the first and only academic Women’s Heart Program in our area. In addition, U.S. News & World Report named us One of the Nation's Best Hospitals for Heart & Vascular Care and recognized us as a High Performing Hospital for Heart Attack and Heart Failure treatment for 2024-25. If you would like to talk with a specialist on our team, contact us at (813) 844-3900 or email heart-vascular@tgh.org to schedule an appointment.