Risk Factors of Peripartum Cardiomyopathy and the Important Role of Prenatal Care.

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Zhiheng He

(3)

American

Journal

of

Cardiovascular

Disease Researah

http://www.sciepub.com/ajcdr/contnnt/3/1

Risk I'eature

in

patients

with Non-ST Elevation Nlyocardial

lnfarction

and

Unstable

Angina

(4)

sci€nce

&

EdLration

Poblishins

l.Introduction

Pe.iparlum Cardiomyopathy (PPCM) is one

ofthc

mxin

foms ofdilated

cardiomyopathy

with

an

unknoM

causc Its prevalence in rhe

Urited

Srares

I

ollhe

2500-4000

livc

delileries, higher

in

Soutb

Anica

(l

nt

1000

lift-birtht

dd

inHaiti (1tu

300

lile

bitht

l,2l

Ihc

latcst

definition

of

PPCM

by

the tlean

Failure

Association

of

the ESC

Wo*ing

Group

in

2010,

is .lraracter;zed

by

jdiopalhic cardionyopathy

hcat

failule

iecotrdary

to

left

ventricular systolic dysftnc{ion

that

occurs at the end ofpregnancy or a few montfis alier

bilth.

Diagnosis

of

PPCM

is

dono

by

elinriraring

other

diagoses.

Echocardiography

Senerally showed left

l entricular dilatation accompanicd Lry hypokinetic and

low

:jecrion fraciion lnay less than,157o [].3,4.51.

PPCM has various

risk

lactors.

but

some

studies

lrggest

the

r;sk faclors that okcn

arises

is

the

age,

:nultiparity,

tlrin

pregmncy.

chonic

hyp€'tension, severe

:reeclanpsia. eclampsia

and Africar

race.

[

4.6]

:nolog),

ofPPCM

is

rot

known for certair, holve\er ore

theory olien mcntioned is the excesslve prolactin

homone

accompanied by

high

oxidative stress

h

pregnant womeD

that

cd

cause danrage to rnyocardial cells. [1.7.8] Cardiac

tuDctioD

cd

retuD

to

noflnal

jn 2l-41% olpatients

wrth carly dcte.tion-

irteNention

and

heatnent

_[],6.91.

PPCM

is

a

ra.e

cardiornyopalhy

and

docuncnted research

is

still very

rec-

therefore

the

pupose

of

this

study is conducted to study the prevalence snd

nsk

factors

for

PPcM-patielrs

;n

Dr.

Hasan

Sadkin

Central

Gcnenl

Hospital (RSHS) in Bandung.

2.

Methods

This

resexrch

was

conductcd

ir

the

Depatrnent

of

Cardiology

and

Vasculd Mcdicine

of

RSHS.

Ba

dung.

All

PPCM

cases

wcrc

separated

fron

cases

{ith

cardiovascul:r

complicltion

nr prcgnant

lvonan

and

file

monrh. iRer

delr\er)

qrrh dragnosr.

.I

c

i"

p

e!iou.

nisiory

ol

te3ll-healthy Domx!-

syDrptoDrs

ald

slErs

of

heaf

fti1ure

appeared

during

prcSnancy

tlat

tad

been

proled

using echogr.phy having caldiotryopalhy. leti

heart

lirilure.

dilatation

of all

cardiac cha

rbers

These

Risk Factors

of

Peripartum

Cardiomyopathy

and

the

Important

Role of

Prenatal Care

Haryani Sasnaya

Pramesryari', Angustinc Purnornownfi,

Toni

Nlustabsnni

Aprllni

D.paihrenl olCardiolog/ aird Vascular Medicine, Padjadjaran Unive.siry, Jalan Eijknan 18, Bandung 40161, hdonesja *Coresponding author: hawa.isasnraya@gmail co

Re ce tre d

Jdn

arr

1 3, )0 1 5

:

uevje.l

Jd nuary) 2 3, 20 1 5 : A.ce?ted

Janlary

27, 20 ! 5

-{bstratt

Pcripadum cardiomyopxthy (PPC\,])

is

orre

oldilited

cardiomyopathy

of

unkro'ln

causc

l-fie aim

of

dris

study

is

to detenire

the

isk

factors

ard

tle

irporlance

of

prcDatal care

(PNC)

This

is

a

descriprive and

analylical

study

with

C|i

Square test

ofPPCM

cases collecGd

Aon nedical

records

Janmry

l,

2011 througtr

Decenber

,11, 2013

ir

tle

Dr

llasan

Sadikin Central

ce

er3i

llospital

as the

topreferal

hosprtd

of

West Java

P.ovincc We

collected

57

PPCNI

cases

(18.7%)

of

305 prcgndr

worne or

6

montbs

postpamrm

with

cardroaascular problems.

Distibutrcn of

PPCM cases

decr*sed

significantly

b-

0.002)

nom 20i

I

(27 parienrs), 2012 (16 patielts). and 2013

(l,l

patients)-

wilh

average

rsc

30.3 (17.9) years, cesarein delivery (43.870)-

perlaginal

(17.5%), lbrceps (15%)- and

vacuun-extaclor

(3.8o/") Regular

pHaral

care was 84 20olo

Lo\\er

solroelunurnc

patients were 63.2%, thercturc the issue

of

wellare can lead to

vuherab;liry to

PPCM.

Conlinncd

diagnosis Ltsing

echography

nade

dmng

postpaturn

uas 52.63%:ud dilcptutum

was 47.5%. Preeclanpsia was 43.80% (p=0 007)

troslly

NYIL\

finctional

class

IV

(86.30%). Echocitrdiography was

pedonrcd

on 57 paticnts hale a\ er age elecnon

ftactlon 14.8%o- global hypoktuetic;n 98.27% palienls. 39.6%

wiih

allcddiac

clambe(

dilalalioq

left

arium andleft

vertdcle

dilalion in 34 48%, ard 2 5 86%

wilh len

! enhioular

dilatation

Tle

hospital

hsed

prevxlcncc was I 8.68%.

wirh

fte

mdonty

(8420%)

was

NYtlA

lirnctional class

lV

lfie

significant

risk

faclors wcrc age

ove.l0 ye

s.

nulliparous.

low

socioeconomic.

and

preeclarnpsia.

This

study

is

probably

the

trsl

report

mcntbning

a

|igh

prcvalcncc of PPCI\4 rn lndonesia. This rcport provides an awareness

ofPPCM

during PNC to prevent

t|e

rnorbidiry

and

tnofaiity.

PPCM disorder rcquircs rcgular and caletul PNC by laking mto accotrnt cxisting

risk

lactors is rhc

ley

rl ar ,s requu

(J

ffJ

i,L,r

\c

Fld

in e\

eri

heairh

ce

r(

Keywords: peripurun car.Jb

t

pathy,

risk|ilctor,

prcftltal

carc,

prcgnd

t

vanan

Cite This

,{rticle:

Hawani

Sasnaya

Prercswari, Augustirc

Punomowati,

and

Toni

Mustahsani

Apnmi-"Risk

FactoA

of Pcr\rarlun

CardiorJryopalhy and the

hnponint

Rolc

of

Prcratal

Care.-

,1,?e.i.dn

Jatlrnul

aj

(5)

,1

nieri.d

.l.,nnl

of Catdiora\.r ldr 1)^^.ate llescdtLh

criteia

have been found

during

last

nonth of

pregnanct

or edli€r

p.eseniation End

5

nronths

riier

deliver-v. The

method used

*as

a rctrospective

dcscriptivc review.

md

aralytical in

thc

fom

ofdata

on the Dredical records

fiom

I

Janudy

2011

io

:l

December

2013.

This

study

has

ltpproled

bv the hospital edncal

cotnnitte€.

The data raere

statistically

,nalyzed

usirg

SPSS

19 and

chi-square

sisnificece

test.

P value smallo

than

0

05

considcrcd

signincdt

3.

Results

A

roral

of

57

patienrs

(16.28%)

wilh

PPCM

were

collected

&on

305 patients

whon

suilercd cardiovascular complications

duing

prcgnancy

dd

5 Dronths postparlum.

The

patient's

distibution bclow

sho\as

a

dccline

fom

January

l,

2011

1()

Decenbff 31,

2013 (Figure l).

,l,lrhougl nany

lilerarLtres suggesled

wilh

high mortalily

in PPCM cases, there was no death

in

our PPCN{ cases.

Characteristics

of

PPCN4

patients

in

this sludy

are shown in Table

L

I

Esu.e 1. PPCNI ca$s lrcD 20lL 10 2013.

]L.

Dercentales sho\n hcrc

is drc nunb$ ol c.ss olPPCNI compaEd

{r&

the nnDbc. of c.ss of

l)rcgnand

\id

c,diova*ular

abnonrallis

nre perccrt.gc ofc0scs

ol

PPCM to dre numbcr of prcen tur L

\o

_{cn ncr}_)carin 201I as

I

I2%. rn

2011asDUch as 0 66%, nr 20l

l

as0 5lt%

'l

$le

1. Gent.Al Ch{mcte.istics Data

T.ble L EchorrrDhic eun'nraLin

r.ho..

d

o!:rdj

\'o.\

22 (.38.6%l 20 (t5.r%)

r5 {26.3%)

56 (98 2%)

l

(r,8%)

I0 (.t7 _2v,)

I

(rj.5%) I a.1%)

4(6.9%)

I

i,1%)

tl121.1%)

8 01,8"/")

3 (j,2%) 2 (.3.4v,)

Seler.

Tri

spidalRcgurgihdon

2 _{3.4yt

Thenpy in

paticnts

with

PPCM

|as

been

in

accordance

rvith thc

thcnpy of

heart

failtlle of

the guidelines

of

the

DSC (l-uropear Sociely

ofClrdiology)

in 2012.

l0 (l? 20%)

21 (46 6A%)

8 (13 80"/")

2 (l 40%)

4 (6 90%) r4 e4. royq)

3

(i

20%)

2 (3.40%)

4 (6 90%)

l0

?oplt

l\4edicarions

rhat

hare

been

given

in

the aliepafum

period

$as tu.c*-mide.

methlldopa,

isosorbide dinitrale;

rrr I<

o".

p"nun

$r t

o,e

nide.

dgrrre.nne-The

tnne

ofdiagnosis

ofpostpartun

PPCM is 52 63%.

antepartum '17.36%

(p:0 502) are

shown

ir

Fjgure

2

Clinic.l

cheactcistics

varied.

with moslly

hearl lailure

(81.20%

NYHA tunctioral

class

tV, a d

15.80%

NYIIA

tunciional class

Ill),

wiih

a

sigrificant diference

(p <0.05)

of

preckldnpsia (35

patieDts, ,11.8%)

conpared

with

₂₈

patieris

(35%)

s'ithout

hypedension. In

this

study

did

not

find

a

knrd

of

potential risks

such as obesily, bad habils (alcoholism, smoking) in ihe case

ofPPCM.

Cadiacdllalrrion L.ft

Ainum

d

l.ft

Vcntrlclc

Globalhrpoknredc:

EF(%):

Cardidcrahcsl

Trivial MiFal RcgrreitaLion

Tnrial Pllnonal Rcgtrrgltalion

Tnrial T.icuspidal RegurgiktioD

Mrld

Ah.l

Regurgitation

Mrld Mitral Rcgurgilalion

Mild Pulnonal Rcgurg,ktion

Mild hcuQidal Re$rrerlalioD

Mod.ral. Milral Regnertitron

N4oderare Tricuspidal Regueiratio.

Sclcf MilJrl Rogurgi lalion

< 20 _r€r-old

20-10

tcd

old

:30yer{ld

Dclircryprccess.

Cesdcd opcration

pcrVaginatu

V.c!m eiraclor Sngb bntll

Snsle pregnd.!

MulLiple pEgnancr

Mulligrardcp.rcus rrcnaralc@(PNC)

Socio-aonoD!: morthly takc honc pa! Lcs than 80 USD

80-,100 usD

> ,100 _usD

1(7 tf/o)

25 _{4:r.90%) 28

tl9

10%)

22 (r8.60%)

2i

(4030%)

l0 (17 5%)

2 (i,jo%)

j0 _{37.?0%)

7 (8,70%) 2i (40,1%)

27 (47

4e

)

1(tz.]Ayo)

I

(15,80%)

48 (8,1,20%)

16(61.20%)

ll

{22 80%)

8 (14,00%)

0.0!0

0001

000r

Preeclampsia: srstolic

-

l40 rmrfig. drasroliki90 rmHg. prcrcinun.

/l

r

'ts

Ic'.'r,o'.,s..',oNlrc''

cs.

'or.'11..!cai,o'

dd

Fj .n

o..r.

'p

.

'o',

^!cn4

o'

ridr

$stolic:

110 mmllg. diasLollc:90tutuHgpr.

pr9incy

or < 20

Figure 2. Thc trmc oldiagnosisofPPCNt

ltse

l,r prcscntation c\islci

in 12 prermnt \omcn (21 0j %)

22 (31r.60%)

rj

(26.j0%)

tf,tAlium

d lcft rcnhclc

Left vcntri.lc!tc.Li.n

F

.Lon

Mital Egueitation: Tnr ial

l!4 d

Tncuspidal r.glrgrtdion: ln\ral

ltitd

P!lmo. al

r:xrgid;on

rri\ial

(6)

Anetica

Jo

tTqlafcdn:

aratc

lot

Dis.av ltescarch

:=

---i-:n

inhibitor,

bisoprolol, nethyldopq

-:r':

f-::.

bromocriptine.

l-

f)ia(Ission

i:

tri\alerce

of

PPCM is very

lare- aithough

it

can

:€

::-:'rh.earening.

Dataofthe

main hospltals

in Southcdt

:..::

:ho$ed

PPCM

occurs

in

089 for

every

1000

:.,:-tarim

women

[ll]

ln

our hospital rfiere were around

l l

li\e

bidhs

per month

(iround

7,200

li\,e births

pcr 3

r

irl

the hospiral based prevalence

of

P PCM is .ronDd I :

Il5

live bhhs,

which

is

higher

compare

with

South

\liica or

Hairi.

The

figure

mentions

I

gcognphical

djffereDce and also indicates pregnant

woncn in

lndoresia lirce

a high

risk oI

PPCM.

The figure

is

also

suggesl ro

erery

health providers,

in

padicuiar thc

obstetrician

ard

nidwir€s,

should

be more vigilant wher

checking

the

heart

condition

of

preg ant women. Alrhough

PPClvi is

olien

difficult

to diaErose, because the symprons

ofhead

l:rilure

resoDrble the

physiological

response

of

p,usxarcy

112.13.141.

'lhe

eralLralion

ofthe

synptons

End sigDs

of

left

lead

la;lule

is

very impotunt

i

PPCN,I suspected

patienrs

_16,7,101.

PPCM

is a

diagnosis

of

exchtsion

'eqLir"s

Ll,

,.1:rl

c\JrIIa,io

r.

au

tlorJ.

ic

,ridgrng ard eclocardiography) to mle oul others [6]

The.esulls

of

echocardiography showed

a

low

eJection

fiadion

value

(34.70%),

wnh

global

hlpokinetic.

dd

dilatated cardiac

c|ambers

by

valvo regurgjtalion, thcrcforc should

locus

on

cardiac fiurction. According

ESC

2012,

t|e

management

and

opfinization

ol

thenpy

is

viral to

i|e

prognosis

of

palients

with

PPCM

reveBibiUty

of

cardiac

tunction

[2.15]

Ccrain

medicalions nccd to tre adjusred

in

palients

with

pregnancy and breastfeediDg- because some drugs

:{e hanntul

to the baby, such as ACE nrhibilors that

bave fetaL

toxicity

and

lor

nursins

Drodrers, because thc drug

is

cxcreted

ifi.ough

the

mlk

can cause hypotension

ed

rcnal

iDrpairmenl

lbr

neonates

with

low

birlh

rveight

or

prcmahre. ACE

inlibitor

class has been

plole

safe

do

captopril, enalapril.

and

quinalap

l

Allemrtive

vasodilators

for

pregrant

and

lactating women

are

neihyldopa,

or

a combination

of

hydralaz

ine

and

nilrale

group.

lhe

beta-blockers

thai

have

beer

proven

sife lor

pregnant wornen are

netoprolol,

horvever

bisoprolol

dd

carvedilol

are

o1

kno'w with

cerlainly

_[,1.16,17]

Bromocripline

is

a new drug

used

in

the

lreatnent

of

PPCM

l]u1

inlibit

thc productioD

of

prolaclin, but

it

still

need a larger srudy

[8,19.201.

PPCM patients should be

nanaged

widr

holistic

approach,

covering

education

for

&e next

pregnincy

and contraceptjon, since thcre arc

risk

of recunency 15.20,2

ll.

J.l.

PPCM

Prevalcnce and

Risk Factors

PDa!I

i.

d

suc:dcd

$ilh

se\er?t

n.k

ta.t,{r.

ie

ice.

-ra

emrl ag<

rnulrip

ous.

rsrn l\|cne-.ior

_i_I

riegnancy,

low

sociocconomic,

and irereguljr

PNC

.1.:.111

lr rl,i.

ruJ\

rizioriq

olPl.M

paner

r. .,

rne

:-.m

low-incolne

lanilics

(63.2070),

therefbrc

it

is

=orta

t

to

consider 1hc issue

of

wellare

oI

the patient

:=

lead to

vulnerability to

PPCM.

h

soine lite.ature, the

=:

mnged

nudy, the

Aon

avcrJ8e 16 to 44 years

age

of

old

PPCM paticnt was

(a\erage 30)

16.l:1. ln

l0.l

r-r:

and

who

are

)oullger

than

30

ycars as rnuclr

as

:.

-- o;. mcars younser age is able to bc a

risk

irdor

drat

should be considered

A

total

oI47.40%

olparienrs

'\ith

PPCIVI

in

this

stud), were

multipdous The

dara

is

supported

by

literature studies rhxt stated

7l%

ofpatienG

wilh

PPCM were

multiparous

113,14-15l

In

this

studt

8.70% patieDts

nith iwin,

almost snnila. to olher resedch showed

9-13%

patients

with

lwin

[6.16]

According

fie

Workirg

Group

OfHeat

Failure ESC 2010, rhe diagnosis

of

PPCNI

is

stdling

at

the

last

gestational

month up

to

several

nonths

postpa.hrm.

In

our

dara

suggesr rher

diagnosis

of

PPC]\,]

can occur earlier, i.e.

during

17-36 weeks

ofprcgnancy

there was 21 05%

of all

PPCM cases

thal can bc categorized as

edly

presentarion [1,61. tn r]]is study PPCI\,l parienrs diagnosed

froslly

in postpartuf!

but did not

differ

rnuch

with

antepartun.

4.2.

The Role

of PNC

for

Early

Detection

of

PPCNI

Prenatal

cee

(PNC) has

!

very

strategic

role

to recognize

thc

emergerce

of

PPCM

Lorn

the bcginning. PNC becaDre the

nost

impor.ant factor

i

fte

handling

of

PPCM

prccisely, becatlse

it

rvas

found

to

appcar earlier

than thc

ofjcial rine

lradrtioDally

tn

dis

study 84 20%

of

PPCM

patients

have

undergone

PNC well

as

r(.r

nl,er

ded

b)

\\

llO.

P\.

Le,ones

lcN

rmpor

a

.

thc carly deteclior ofsynrptoms

ofPPCN,I

for previousi)

heart-healtfiy

pregmnt

womcn.

The

Fert's

self test lbr

recognition

of

heart

fitiluc

durirg

pregnancy

and

after

deliyery would be very

helpftl

when applied

to

cvcrl

preglanl

woman

and

also

nronitoring

posGPPCM

pregnancy

l22l

Pat;erts

wilh

PPCM nr dris srudy, 46.39i,

were

Aom low

socioecononnc.

which is associited

wrth

rnalnutrition as

a dsk

factor

for

the orsel

of

PPCM

L

5.1-

8l v"l,eb

qlo

comc

Iorn

all

\ocio-econor--layers should gct the same allention coDside ng rhal rhey

iequire

an e\planation

of

the PPCM

drd

rhen

nusl

be

widely

disscminated

For ihal

reason

knos'ledge

abour

PPCM should bc dissetniDaled to eveD, doctor, nurse

lrld

pregnant

wonrer

to reporl their suspicioDs and 1() refbr the

lalient lor

tunhcr clinical exanination

to thc

c,rdiologisr.

The hospital

based prevalence

was 1868%-

Iriih

the

najority

(84

20%) was

NYHA

lunctional

class

lV.

Thrs

study

is

probably

the

first

report

nrdicares

a

high

prcvalence

ofPPCN4

Indonesia

This

report can be used

as a b!-sis tor more awareness

ofPPCM

ir

order to prevent and

to

decrcrse

the

mo.bidily

and

noftality

ol

pregnanr

wotnen. Thc n€w lirerature

srares

a plual

associared

predisposition

including genetic, nevctheless

clinical

lierv

to

faco

the PPCM

disorder

requircs regular

ard

ffreful

PNC

bytak;ng

into account existing risk lactors is drc

kcy that

is required and must bc

held

in

every health

References

l1l

SlnM

K.lJrlfil{d

(lciier

D.Pefrie MC,NIcbaTaa A.Pieste

B.Buchnrnn E. et

il

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di,,

ro...

_",.r.'ten

er

r

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I n

caidiomlopalhr:

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lron

the Hean F.iluc As$cirlion

ol

dre

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ol

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Il8l

ndcreon

JL

Home

BD

Binnne dre genelics

ol

pcntarLun

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l2l

2lj7 j9

ll9l

sbafiq

MXhn

R-A.Kb

r

A.Shrh A.Hussain S tjtccoeniscd

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JA.

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I

Pirk Nlcd

lsso.

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[2]l

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[22]

rcrL JD

valid

io. or a

*lrrc(

for cal\ diienosn ol

tea

Lllur

in

penfanu

cddionloprthy CriLical PadNals nr Cardiolos;.

Risk Factors of Peripartum Cardiomyopathy and the Important Role of Prenatal Care.

\olume

TitnirP.ul

hl.rdlllnreNiLr

lInr.6ili

1]ojnlal.

CONTENTS

Risk I'eature

inHaiti (1tu

Diagnosis

chonic

still very

cases

dilatation

uevje.l

Distibutrcn of

vertdcle

Keywords: peripurun car.Jb

dcscriptivc review.

distibution bclow

spidalRcgurgihdon

shown

:30yer{ld

tf,tAlium

bidhs

condition

c|ambers

birlh

kno'w with

rnulrip

ycars as rnuclr

PPCIVI

stud), were

during

ofjcial rine

deliyery would be very

iequire

lunctional

ffreful

Cunlbins.

Drp.,,p,n,,,,aoo,r,p.{\\

Lllur