Snapshot A 34-year-old G4P3 woman of 37 weeks gestation presents to the hospital with progressive dyspnea and fatigue over 2 weeks duration. On physical exam, she is found to have bilateral lower extremity edema, bilateral basilar rales, and extra heart sound following S2 at the apex. She has jugular venous distension. A chest x-ray is done which confirms the diagnosis . She is started on supplemental oxygen and intravenous diuretics. Introduction Overview peripartum cardiomyopathy (PPCM) is a rare, idiopathic complication of pregnancy that results in left ventricular systolic heart failure in women during the peripartum period this is a potentially life-threatening condition that requires urgent evaluation, diagnosis, and intervention treatment similar to other forms of heart failure Epidemiology Incidence rare, 0.04-0.10% of live births Demographics onset between 36 weeks gestation and 5 months postpartum usually occurs within 1 month postpartum Risk factors pre-eclampsia or eclampsia pregnancy-induced or pre-existing hypertension advanced maternal age multiple gestation high parity african-american ETIOLOGY Pathogenesis mechanism largely idiopathic, may be related to systemic angiogenic imbalance, elevated oxidative stress, and impaired VEGF signaling during pregnancy Presentation Symptoms common symptoms chest pain heart failure symptoms exertional dyspnea cough orthopnea paroxysmal nocturnal dyspnea Physical exam bilateral lower extremity edema jugular venous distension displaced apical pulse abdominal fullness bilateral basilar crackles S3 gallop Imaging Chest radiograph findings enlarged cardiac silhouette pulmonary vascular congestion Kerley-B lines interstitial edema Echocardiogram indication imaging study of choice in the diagnostic evaluation of PPCM findings decreased left ventricular ejection fraction Studies B-type natriuretic peptide (BNP) usually elevated in PPCM, greater than in pregnant or postpartum women Electrocardiogram (ECG) findings sinus tachycardia nonspecific ST or T abnormalities comments as findings are nonspecific, ECG is generally done to distinguish PPCM from other conditions like pulmonary embolism Differential Pulmonary embolism key distinguishing features will present with dyspnea with no evidence of left ventricular dysfunction or enlarged cardiac silhouette on imaging Treatment Management approach similar to management of heart failure except teratogenic medications (e.g., ACE-inhibitors, angiotensin receptor blockers (ARBs), aldosterone receptor antagonists) are avoided in pregnant women Conservative spontaneous vaginal delivery preferred mode of delivery for hemodynamically stable patients Medical ACE-inhibitors or ARBs indication for postpartum patients or pregnant patients following delivery hydralazine and nitrates indication for patients who cannot take ACE-inhibitors or ARBs β-blockers indication for long term management in all patients spironolactone or eplerenone indication treatment option for postpartum patients or pregnant patients following delivery diuretics indication for symptomatic treatment of patients with evidence of pulmonary edema Surgical immediate delivery via cesarean section indications severe heart failure hemodynamic instability refractory to treatment Complications Ventricular tachyarrhythmias Chronic cardiomyopathy occurs in women with baseline left ventricular dysfunction Prognosis More than 50% of patients recover within 6 months with medical treatment 6-10% mortality earlier diagnosis associated with improved survival