Diagnose PPCM by echo, treat heart failure with pregnancy-safe drugs, consider bromocriptine with anticoagulation, and escalate early to mechanical support in shock.
At the bedside
- 1
Suspect and confirm
Breathlessness, orthopnoea, oedema late pregnancy/postpartum: BNP/NT-proBNP, ECG, echocardiography; exclude pre-eclampsia, PE, AFE, myocarditis, pre-existing cardiomyopathy.
- 2
Acute HF
Oxygen/NIV, IV furosemide, nitrates if BP allows; avoid ACEi/ARB/ARNI/MRA/SGLT2i before delivery (use hydralazine-nitrate); beta-blocker (metoprolol) once stable.
- 3
Cardiogenic shock
Early transfer to a centre with MCS; levosimendan preferred inotrope (catecholamines, especially dobutamine, may be harmful in PPCM); IABP/Impella/VA-ECMO; urgent delivery if antepartum.
- 4
Bromocriptine
2.5 mg BD for 2 weeks then daily for 6 weeks (severe, EF < 25% or shock), always with anticoagulation; stops breastfeeding.
- 5
Anticoagulation
Therapeutic anticoagulation for LV thrombus, AF or EF < 30-35% (high thrombosis risk peripartum); at least prophylactic with bromocriptine.
- 6
Postpartum
Full guideline-directed HF therapy (ACEi/ARNI, MRA, beta-blocker, SGLT2i if not breastfeeding); counsel on future pregnancy risk.
PPCM (severe)
Bromocriptine
- Dose
- 2.5 mg BD × 2 weeks, then 2.5 mg daily × 6 weeks
With anticoagulation.
References
- 1
- 2
- 3
Pathophysiology
Oxidative stress cleaves prolactin into a 16-kDa fragment that is anti-angiogenic and cardiotoxic; together with sFlt-1 (high in pre-eclampsia) and genetic predisposition (titin variants), this causes cardiomyocyte and endothelial injury - the rationale for bromocriptine.
Evidence
- HFA ESC 2019 position statement [Bauersachs 2019]; ESC 2018 pregnancy guidelines [Regitz-Zagrosek 2018].
- Bromocriptine RCT (63 patients): no difference between 1 and 8 weeks; high recovery rates in both [Hilfiker-Kleiner 2017].
Controversies
- Bromocriptine efficacy (no placebo-controlled RCT completed); levosimendan vs other inotropes.
🇮🇳 India notes
- PPCM incidence is relatively high in parts of India; anaemia, multiparity, pre-eclampsia and malnutrition are associated.
- Mechanical circulatory support is concentrated in metropolitan centres; early referral is crucial.
References
- 1
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