Dr. Fett is this true?

[SarahsMom]

Dr. Fett,

Hello, hope you're doing well! I'm 8 weeks pregnant with my post-PPCM baby. I went to the Perinatalist on Tuesday and the MD said that if my cardiologist does and echocardiogram at the end of the 1st trimester and it's normal (no decline in heart function), chances are I'm in the clear? That I probably will not have a reoccurance of PPCM. He said that most of the heart output happens in the 1st trimester??? It could be right for all I know, the first pregnancy we weren't concerned about my heart so no echo's were ever run. That didn't sound right to me but, I didn't question it-->thought I'd run it past you first.

My OB said he'd like to do an amnio at 34-35 weeks and if the baby is full term, he'd like to go ahead and deliver he/she. He said that he'd like to get the "dynamite out of the hole." as all my previous problems started at 36 - 37 weeks.

What do you think about the above.

Thanks,
Kari

[JAMESFETT]

Not wishing to contradict info you have, but my experience is that we don't yet know enough to be sure. I also don't want you to have to fear relapse during your entire pregnancy. However, the relapses (worsening or re-appearance of heart failure) I have seen from later pregnancies in PPCM patients (personal experience with over 20 patients) have been during the 2nd and 3rd trimesters of pregnancy and first two months postpartum. I would not at all feel secure with data from just the first trimester, but would be alert to subsequent developments. For that reason the repeat blood tests for BNP and CRP can be helpful. The early delivery, compatible with fetus/neonate maturity and safety, sounds good. I honestly don't know the additional risks from amniocentesis, but in experienced hands that should be very small indeed. Here's when I feel secure about freedom from relapse:

1)at least 2 months postpartum and
2)normal plasma BNP
3)plasma hsCRP 5 or less.

But I also feel reassured with each normal echo and lab value done in each trimester and postpartum along the way.

JD

[JAMESFETT]

P.S. The reason the first trimester data do not tell the whole story is that all that stage indicates is the extent of healing following the previous PPCM. It is true the first trimester has a peak in heart stress, another peak follows in the 8th month, so if your heart tolerates that it is a good sign, just as your doctor says. But the process of development of PPCM gathers steam as the immune system returns towards its normal level after being blunted in order to tolerate the pregnancy, that's why we see so many PPCM patients developing symptoms following delivery (or at very term pregnancy). That inflammatory process comes late, so we need additional observations later than the very first trimester ones. Rising BNP tells us things before the echo does, and rising hsCRP tells us things earlier than any other test. I feel confident in advancing this idea about CRP because we have such strong data to back it. Furthermore, other centers have been able to duplicate the importance of hsCRP levels in inflammatory cardiomyopathies/PPCM.

JD

[miachic]

So if the hsCRP and BNP levels start to rise towards the end of pregnancy, what can be done? If the patient is showing signs of developing PPCM during the last few weeks of pregnancy and/or postpartum, is there anything that can be done to "ward off" the full blown effect with reduced EF, CHF symptoms, etc.?

Emily

[JAMESFETT]

Emphatically, yes! With advance warning, the obstetrician can as vigorously as possible search for fetal maturity that would permit Cesarean section at the earliest safe moment. In other words, delivery helps in the recovery. In addition, safe medications can be added at an earlier time. Particularly this would mean beta-blockers, and probably that would be carvedilol. With delivery, an ACE-I or ARB could be added. Both of those medications have an effect beyond hemodynamic helping the circulation, they have an effect to dampen an overactive immune system, to cool down an inflammatory process. Diuretics can be used according to fluid-overload conditions. When these methods are not sufficient to control the situation, there is an "ace-in-the-hole" waiting to be applied/tested, which is apheresis or the filtering of blood to remove something hurtful--that something is not yet known, whether immune complexes or autoantibodies or something else. Whatever it is, getting these noxious substances out of the system is often associated with improved left ventricular systolic function.

JD

[miachic]

Huh. Another helpful and interesting thing that I can pass on to my OB and cardiologist. You are just wonderful Dr. Fett! I would just love to meet you in person and shake your hand (or give you a big fat hug) for being there for all of us!

Emily

[JAMESFETT]

Be glad to discuss any of this with your Ob or cardiologist, I know that many times info received uninvited over the internet is not always welcome. But our data are strong, and PPCM is my specialty, I've been blessed with the opportunity to work on this, despite my advanced age, I say that I am a "backwards teenager" (17). There is nothing exciting about me, but work on PPCM is quite exciting. We have developed a network of collaborators in multiple places on the globe, and our goal is to find answers, for which we make some progress, slow but sure. Add another global partner: Just today I have been able to initiate meaningful dialogue, hopefully leading to collaboration, with a group in Sotolo, Nigeria, where they have a high incidence of PPCM, and are developing a research project.

JD

[tabs]

I would just like to echo Dr. Fett's concern about only having an echo in the 1st trimester. I was followed throughout my third pg as it was discovered at 12 weeks gestation to have an EF 43%. I had regular echos and follow up until 30 weeks and they were all the same. At that point my cardio decided I would be safe until after delivery. Unfortunately that was not the case and I started to have some mild symptoms (right sided abdominal pain which is now known to be a symptom of CHF only in pregnant women - see article on E-med which is linked on the main site). It is best to be monitored throughout the pg.
Twilah

[mikeyandBellesmommy]

I was normal in the first trimester as well 65% and by my 35 week echo I was at 40%. My OB did tell me though that if you can tolerate the 1st trimester it is a sign you will do well but I dont think they know enought to say that.

Also I believe my quick recovery with PPCM # 2 was quick diagnosis and quick action. .. Mikey was taken as soon as the decline happened and although his lungs wehre still a little immature he was a perfect 7lbs and I did very well and I was in maternity by the 3rd day post delivery.

[JAMESFETT]

For next pregnancies in known PPCM patients, if physicians will consider doing the BNP and CRP blood tests each trimester and 1 to 2 months postpatum, they will have a heads-up on what is coming down the line, in the case of relapses (may they never happen!). The combined cost of the two tests should be less than $50 each time done, that's a cost that will be many times less than the cost of acute medical care for delayed recognition of relapse.

JD