Question for Dr. Fett

[Kimberly Sidden]

Hi! Dr. Fett, I am a new member, was diagnosed with PPCM a week after the birth of my first child, 1/13/04. My blood pressure was 180/120 and I had an EF of 40%. I was treated with lisinipril, coreg, and lasix. I had gained over 75 lbs, 40 of it was fluid, I had severe pitting edema at the end of my pregnancy. I was taken off medications in May of 04, with an EF in the 50% range and had my one year check up and echo in August and my heart was "totally back to normal" with an EF in the 60's%. I was a smoker and quit during that pregnancy. I just found out that I am 7 weeks pregnant with our second child (surprise), and I just turned 40 a couple of weeks ago. I am wondering what the chances are of having PPCM with this pregnancy, how I can mitigate that risk , should I see my cardiologist throughout the pregnancy? are there tests that I should be doing, when should I have another echo? Any words of advice would be very much appreciated.

Kimberly

[JAMESFETT]

Prayers and best wishes, Kimberly. With your first pregnancy, did you have toxemia (pre-eclampsia) or "simply" hypertension of pregnancy? I assume that your BP is now normal.

I hope and pray you will do well during this pregnancy.

It is best to have an echo in each trimester of your current pregnancy, more often only if parameters are worsening. Perhaps your August echo counts for first trimester. So next one at about 5-6 months pregnancy, unless clinical symptoms earlier. And the third in your last month of pregnancy, then a followup in 1-2 months after delivery, just to be sure everything is holding well.

Yes, regular visits to your cardiologist during your pregnancy are important.

Helpful lab: blood BNP during each trimester. An elevation can preceed clinical symptoms of heart failure.

Helpful lab: blood high sensitivity CRP each trimester, if level goes above 10 mg/L that would be suspicious for developing inflammatory process. The first one serves as baseline. You can expect some rise with a normal pregnancy, but since it has not been studied adequately in normal pregnancies, I don't know how much it goes up with a normal pregnancy, I would guess between the 5 and 10 mg/L figure.

Feel free to contact me any time, you and or your physicians.

JD

[miachic]

Just reading along here. Dr. Fett, just curious why you asked if she had preeclampsia? What's the significance for the questions that she asked?

Emily

[JAMESFETT]

Very severe toxemia of pregnancy can also cause heart failure. If any other cause of heart failure can be found, then by definition, one cannot diagnose PPCM. In over 150 PPCM patients we have found overlap of toxemia in less than 15 percent. I do not consider toxemia of pregnancy as a "risk factor" for PPCM, just a co-existing condition in some PPCM patients. I believe our data from Haiti, and Dr. Karen Sliwa's data from South Africa present convincing evidence that toxemia and PPCM are two separate processes, and that toxemia is not a "risk factor" in the pathogenesis of PPCM. HOwever, both toxemia and "hypertension of pregnancy" put extra stresses on the heart and in a person with developing PPCM, the clinical symptoms of heart failure may then appear earlier.

JD

[miachic]

Huh, very interesting. My heart failure doctor said nothing about this and I have thought all along that my severe pre-e had something to do with my HF and PPCM. When I went in my BP was 196/130 and my HR was something crazy like 140s. I had fluid in my lungs already, 4+ pitting edema, and 3+ protein in my urine. I have to wonder now if I was already in CHF and they just didn't diagnose it. I also wonder if they would have diagnosed it and gone ahead with pushing Lasix if I would have ended up as bad off as I was.

My BP five days before delivery was 154/100 but no protein in the urine so we set an induction date for eight days later. Baby decided to come early...or should I say my body decided to freak out on itself. I am wondering if my high BP and eventual pre-e for those days following up to delivery just made my heart too tired and it pooped out and put me in CHF. Hmmmm. Very interesting!

Emily

[miachic]

P.S. From what I'm getting from your post, is there a way that they could diagnose CHF due to pre-e as opposed to CHF due to PPCM? I am convinced that I do have PPCM because of all my studies up to date and everything the doctors have told me but is there a difference in how it would be diagnosed? Would I have the same problems, low EF, enlarged left ventricle, with CHF induced by pre-e? I'm still trying to figure out what exactly gives me my diagnosis. There's so much information that it's hard to narrow down what to believe and since I'm getting varying information even from my cardiologist to HF doctor, it is just all so confusing to me. I wish you were my doctor! You sound much more experienced in all this than both my doctors are and sound like you would be able to help more with a more definitive diagnosis and treatment plan :).

Emily

[tabs]

Emily, I can understand your concern about the CHF and where it came from. It is all very confusing and made more difficult by the lack of knowledge about PPCM. As more research is undertaken, hopefully questions like these will be better answered. I mention this because we just had a women at my church who had to give birth early as she was in CHF. I thought to myself, now I know why God moved us here.....so that I could help. Nope! The doctors here, after telling her and her husband, while she is in the ICU, it is either her or the baby, we will do our best, but..... are not even concerned about her heart. They feel that her CHF was a result of severe pneumonia. THe fluid in her lungs built up enough to fill up her heart. They delivered the baby, pumped off the fluid, and voila.... they feel no more CHF and no more follow-up re heart. I talked to her about PPCM, but she does not feel that her heart is a problem. For that I am extrememly gratefull!
Twilah