Screening for PPCM

[JAMESFETT]

Here is the medical history test that I propose for screening every woman for PPCM during the last month of pregnancy (feel free to share with your ob doc):

Focused Medical History for PPCM Screening:

1. Orthopnea (difficulty breathing while lying flat):
a)None =0 points; b)1 pillow = 1 point; c)2 or more pillow = 2 points

2. Dyspnea on exertion:
a)None = 0 points; b)Climbing 8 or more steps = 1 point; c)Walking on level = 2 points

3. Unexplained cough:
a)None = 0 ponts; b)Night-time = 1 point; c)Day & Night = 2 points

4. Swelling lower extremities:
a)None = 0 points; b)Below knees = 1 point; c)Above and Below Knees and/or other body parts = 2 points

5. Palpitations (sensation of irregular heart beats):
a)None = 0 points; b)When lying down at night = 1 point; c)Any time day or night, any position = 2 points

Total: 0 points = no risk, no additional testing
1 - 4 points = mild risk, consider doing blood BNP and CRP; if either over cut-off point, consider doing echocardiogram
over 4 points = high risk, do blood BNP, CRP, echocardiogram

JDFett, MD

[LauraNP]

My only comment is the orthopnea question. When I first read it I thought that it meant that if you sleep with 2 pillows you're sick. Maybe it could read pillows needed to prevent orthopnea?

Just a thought.

[SusanD]

Dr.Fett, I think having a screening tool is a WONDERFUL thing. Somehow we need to quantify weight gain within the tool. I would hope there is some literature somewhere that defines a normal expected weight gain week-by-week in the last trimester of pregnancy VS. the weight gain a lot of women here experienced. For instance, I gained 10 lbs within a week :eek: .

For validating this tool, might I suggest having our members fill this out. I realize one of the weaknesses of the study is that a certain amount of time has passed for a lot of us, but it would still be at least a start.

GREAT JOB. If I was feeling brave I would take this on as a thesis project for my masters, but I don't know if I am up to the task.

[SusanD]

My only comment is the orthopnea question. When I first read it I thought that it meant that if you sleep with 2 pillows you're sick. Maybe it could read pillows needed to prevent orthopnea?

Just a thought.


I agree....I think we can narrow this down further to reflect more of what reflects our disease state. I didn't use pillows at all.......I headed straight for the recliner in the nursery.

[JAMESFETT]

Thank you for the great ideas! Feel free to use/adapt this to your heart's desire. It would be interesting to have a "retrospective" analysis of what people experienced. Also a "prospective" analysis of women in last month of pregnancy. In my own copy, I am making adjustments according to your recommendations. I am working this up for a scientific journal manuscript, such as American Journal of Obstetrics and Gynecology or Obstetrics Gynecology.

JD

[JAMESFETT]

Focused Medical History for PPCM Screening during last month of pregnancy:

1. Orthopnea (difficulty breathing while lying flat):
a)None =0 points; b)Need to elevate head = 1 point; c)Need to elevate 45º or more = 2 points

2. Dyspnea (shortness of breath on exertion):
a)None = 0 points; b)Climbing 8 or more steps = 1 point; c)Walking on level = 2 points

3. Unexplained cough:
a)None = 0 points; b)Night-time = 1 point; c)Day & Night = 2 points

4a. Swelling (pitting edema) lower extremities:
a)None = 0 points; b)Below knee = 1 point; c)Above and below Knee = 2 points.

4b. Excessive weight gain during last month of pregnancy:
a)Under 2 pounds per week = 0 points; b)2 to 4 pounds per week = 1 point; c)over 4 pounds per week = 2 points.

5. Palpitations (sensation of irregular heart beats):
a)None = 0 points; b)When lying down at night = 1 point; c)Any time day or night, any position = 2 points

Scoring: 0 points = low risk, no additional testing
1 - 4 points = mild risk, consider doing blood BNP and CRP
5 and more points = high risk, do blood BNP, CRP, echocardiogram

JDFett, MD
14 April 2007

[tabs]

Dr. Fett,

That is wonderful and easy to read and administer! FYI with my very first pregnancy I would have scored at least 6 which would have led to a dx with that pg instead of waiting over 5 years.

Twilah

[SusanD]

I would have been a 6 using your assessment tool.

So what is the next step ? Administer this tool to X amount of pregnant women in the last trimester, measure how many developed PPCM and how their scores correlate with a diagnosis or non-diagnosis ?

[JAMESFETT]

Interesting how you would have scored! I think it would be good to run this by some obstetricians for input and recommendations? If these questions were in minds of caregivers in the last month of pregnancy, I think it would help to pick up over 95 % of women with impending heart failure from whatever cause, be it valvular heart disease or PPCM or IDCM or FDCM.

JD

[CarlaW]

What you have put together looks fantastic! It is so important to get this out there. I would have scored a 10. Maybe if I had been asked these questions I wouldn't have had to spend 15 months feeling terrible before being diagnosed. Thank you for all the wonderful work you are doing.

[Elliesmom]

this is really helpful, i can now rationalize & state what it is i am feeling with this point system. as of now i am 5 weeks and 3 days away from my c section and i am at a 2, at this point in my pregnancy with ellie i would have been a 9

this is a wonderful tool, thank you so much!

[JAMESFETT]

Thanks for the feedback. I'll work with the scoring since probably up to a 2 simple observation alone is sufficient.

JD

[Erin]

Oh, this is great, Dr. Fett. I'm putting a packet together for my OBGyn and I'll definitely include this peice -- I'm hoping to visit with him briefly at the beginning of next month.

I'm planning an educational campaign for the cities of Mesa, Tempe and Chandler. Right now I'm planning a mailing and some personal visits to OBGyns, L&D Department heads, and cardiologists in my area. There are about 10 hospitals with L&D units, 50 cardiologists and 85 OBGyns. My husband is helping me as well. I'm excited.

By the way, I would have scored a 10 on the screening.

[LauraNP]

Focused Medical History for PPCM Screening during last month of pregnancy:

1. Orthopnea (difficulty breathing while lying flat):
a)None =0 points; b)Need to elevate head = 1 point; c)Need to elevate 45º or more = 2 points

2. Dyspnea (shortness of breath on exertion):
a)None = 0 points; b)Climbing 8 or more steps = 1 point; c)Walking on level = 2 points

3. Unexplained cough:
a)None = 0 points; b)Night-time = 1 point; c)Day & Night = 2 points

4a. Swelling (pitting edema) lower extremities:
a)None = 0 points; b)Below knee = 1 point; c)Above and below Knee = 2 points.

4b. Excessive weight gain during last month of pregnancy:
a)Under 2 pounds per week = 0 points; b)2 to 4 pounds per week = 1 point; c)over 4 pounds per week = 2 points.

5. Palpitations (sensation of irregular heart beats):
a)None = 0 points; b)When lying down at night = 1 point; c)Any time day or night, any position = 2 points

Scoring: 0 points = low risk, no additional testing
1 - 4 points = mild risk, consider doing blood BNP and CRP
5 and more points = high risk, do blood BNP, CRP, echocardiogram

JDFett, MD
14 April 2007

Another thought- you might want to add fatigue and exercise tolerance changes although that is a normal part of pregnancy. When I was diagnosed I would have only scored a 4 although I wasn't pregnant at the time. This might not pick up the subtle cases although I agree it's a start.

[JAMESFETT]

Nice to read your comments and suggestions. Anything anyone can do to help with earlier diagnosis, that's great! I have chosen not to make it any longer than it is, and find it too difficult to quantitate fatigue. Thanks again.
JD

[JAMESFETT]

Focused medical history for PPCM screening during last month of pregnancy:

1. Orthopnea (difficulty breathing while lying flat):
a)None =0 points; b)Need to elevate head = 1 point; c)Need to elevate 45º or more = 2 points

2. Dyspnea (shortness of breath on exertion):
a)None = 0 points; b)Climbing 8 or more steps = 1 point; c)Walking on level = 2 points

3. Unexplained cough:
a)None = 0 points; b)Night-time = 1 point; c)Day & Night = 2 points

4. Swelling (pitting edema) lower extremities:
a)None = 0 points; b)Below knee = 1 point; c)Above and below Knee = 2 points.

5. Excessive weight gain during last month of pregnancy:
a)Under 2 pounds per week = 0 points; b)2 to 4 pounds per week = 1 point; c)over 4 pounds per week = 2 points.

6. Palpitations (sensation of irregular heart beats):
a)None = 0 points; b)When lying down at night = 1 point; c)Day and night, any position = 2 points

Scoring: 0 - 2 = low risk, continued observation
3 - 4 = mild risk, consider doing blood BNP and CRP
5 or more = high risk, do blood BNP, CRP, echocardiogram

JDFett, MD
14 April 2007

[Erin]

Another thought- you might want to add fatigue and exercise tolerance changes although that is a normal part of pregnancy. When I was diagnosed I would have only scored a 4 although I wasn't pregnant at the time. This might not pick up the subtle cases although I agree it's a start.

Just wanted to suggest that perhaps the screening as is does still work for someone who would score a 4 because with that score, the instrument cues the physician to further investigate by performing a blood BNP and CRP -- elevated levels should indicate echocardiogram, if I'm not mistaken.

Dr. Fett, I have a question -- I wondered why you recommend CRP instead of hsCRP? Thanks.

[JAMESFETT]

Most if not all labs only do the high sensitivity test these days, so if a lab's repertoire includes CRP, as most do, that will be the hs test, which it should be, of course. I think everyone is using the hs kit these days.

JD

[LSmith]

I would have scored a 7. Wonderful idea!

[JAMESFETT]

I've called this a screening tool for PPCM. More specifically, it is a screening tool for heart failure. There are more non-PPCM causes of peripartum heart failure in the USA than PPCM as a cause. Importantly, this leads to doing what is necessary to learn IF and WHY there is peripartum heart failure.

JD

[heidiross]

Dr Fett, I will copy your screening if that is okay and give it to my OBs. Sounds great to me.

[JAMESFETT]

Feel free to use this as you think may be helpful. It is available to anyone with interest. If anyone has followup questions or suggestions, also feel free to contact me via this thread/website.

JD