|Year : 2021 | Volume
| Issue : 2 | Page : 54-57
Peripartum cardiomyopathy in Indian population: A pooled analysis
Rakesh Agarwal MBBS, MD, DM 1, Rashmi Baid MBBS, MS, DNB, CCGDM 2, Dhurjati Prasad Sinha MBBS, MD, DM 3
1 Department of Cardiology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
2 Department of Reproductive Medicine, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
3 Department of Cardiology, ILS Hospitals, Kolkata, West Bengal, India
|Date of Submission||21-Sep-2020|
|Date of Decision||23-Jan-2021|
|Date of Acceptance||15-Mar-2021|
|Date of Web Publication||22-Jun-2021|
Dr. Rakesh Agarwal
AJC Bose Road, Kolkata-20, West Bengal
Source of Support: None, Conflict of Interest: None
Introduction: Peripartum cardiomyopathy (PPCM) refers to heart failure of unknown etiology in later gestation or early postpartum period. Data regarding its incidence, clinical features, risk factors, and outcomes in the Indian population are scarce. Materials and Methods: We performed a pooled analysis of seven Indian studies on PPCM, including 221 patients to study PPCM. Results: The incidence of PPCM in the Indian population was 1 in 1340 live births. Indian women developed PPCM at a mean age of 27 years and most commonly in the postpartum period (60% cases). Hypertensive disorders and anemia were associated with PPCM in nearly half the number of patients. Maternal mortality was 11.7% and fetal mortality 14.2%. Conclusion: Our study provides data on PPCM in the Indian population. Larger studies with higher number of patients are needed to study PPCM in detail in the Indian subset.
Keywords: Medical complications in pregnancy, obstetric complications, peripartum cardiomyopathy
|How to cite this article:|
Agarwal R, Baid R, Sinha DP. Peripartum cardiomyopathy in Indian population: A pooled analysis. J Clin Prev Cardiol 2021;10:54-7
| Introduction|| |
Peripartum cardiomyopathy (PPCM) refers to heart failure of unknown etiology occurring during the last few months of gestation or immediately following delivery. Diagnostic criteria include diagnosis within the first 5 months of the postpartum period or in the last month of gestation.
Incidence varies between 1:15,000 and 1:100. Data about incidence from India are lacking. Risk factors for the disease include advanced age, black race, hypertensive disorders, multiple gestation, anemia, and long tocolysis. Similar to scant data about its prevalence and clinical features in the Indian population, data about clinical outcomes and mortality are also lacking.
We attempted to do a pooled analysis of data from different Indian studies on PPCM and to study its prevalence, risk factors, clinical features, and outcomes. This is the most comprehensive review done on the Indian population till date, to the best of our knowledge.
| Materials and Methods|| |
We searched for Indian studies on PPCM on PubMed and Google Scholar. Relevant entries were selected. We found seven studies done during the last 20 years and included all the available data from them to include in the pooled analysis. Studies included two from western India,, two from eastern India, and one from northern India, and two from southern India., Data for 221 patients were available.
| Results and Analysis|| |
Data were available for a total of 221 patients. The mean age of patients was 27.41 years. About 40% had symptom onset before delivery, while 60% had symptom onset after delivery [Table 1].
Associated conditions identified were multiple pregnancy in 10% of cases, hypertensive disorders in 46% of cases, anemia in 45% of cases, gestational diabetes in 9% of cases, and hypothyroidism in around 7.8% of cases. Fifty-six percent of patients were primigravida [Table 2] and [Figure 1].
Almost all patients were reported to have dyspnea with at least 32% in New York Heart Association (NYHA) FC II, 44% in NYHA FC III, and at least 29% in NYHA FC IV. Other reported symptoms were cough, chest pain, and hemoptysis. The cardiogenic shock occurred in 15% and central or peripheral embolism was reported in at least 8.6% of cases. Data for use of supplemental O2, noninvasive ventilation, invasive mechanical ventilation, and intra-aortic balloon counterpulsation (IABP) were available for only one small study of 16 patients and need further evaluation [Table 3] and [Figure 2].
Maternal mortality occurred in 11.7% of cases. Fetal mortality was reported for 14.2% of cases [Table 3] and [Figure 2] and [Figure 3].
Electrocardiogram (ECG) data were available for 106 patients. Mandal and Binu reported 100% prevalence of sinus tachycardia, making it a sensitive yet nonspecific sign. About 2.8% of patients had atrial flutter, while VT was reported in 2 out of 106 patients.
Mode of delivery
Fifty-nine percent had vaginal delivery, while 41% had to undergo cesarean section for obstetric reasons [Table 4].
| Discussion|| |
Known to be an idiopathic myocardial disease associated with pregnancy, data regarding PPCM from India are scarce. Through this pooled analysis, we attempted to decode the state of PPCM in India.
An incidence of 0.75 per 1000 live births (1 per 1340 live births) was found. The highest incidence has been reported from Nigeria (1 in 102 deliveries) and the lowest from Japan (1 in 15,533 births). In the United States, PPCM is known to occur per 4000 live births. The incidence is known to vary with race and region. However, it is difficult to evaluate ethnic or racial differences in the Indian population in the absence of robust data.
The mean age of patients was around 27 years. It is known that an age over 25 years is a risk factor for the development of PPCM, and a mean age of 30 years has been identified. Indian PPCM may have an early onset compared to other countries.
Sixty percent of cases had their symptom onset after delivery in the Indian population. This seems to not correlate with the timing of major hemodynamic shifts in the body. However, caution is warranted as different studies, even in other parts of the world, have reported different timing of onset of PPCM.,,
Worldwide, hypertensive disorders of pregnancy, anemia, and African descent have been known to be risk factors for PPCM. Our study identified hypertensive disorders and anemia in almost half of the patients in the Indian subset. Other associations reported were gestational diabetes and hypothyroidism.
Almost all patients report dyspnea with almost one-third being NYHA FC IV at presentation. Dyspnea is known to normally occur in pregnancy and a diagnosis of PPCM is often overlooked in these patients. Cough, chest pain, and hemoptysis also occur in a significant proportion of patients.
Almost 15% of patients were reported to have cardiogenic shock. This may reflect late diagnosis and could lead to higher mortality if not properly managed. Data on the use of O2 or ventilation were available only from one study where all patients needed supplementary O2 and at least one (out of 16) needed IABP use.
For studies that reported ECG changes, sinus tachycardia was ubiquitously present, while atrial fibrillation/flutter and VT were reported in a minority. Data on recovery are inconsistent and difficult to evaluate in light of the incoherence of the studies. However, a higher left ventricular ejection fraction at presentation, and a smaller left ventricular end-diastolic diameter may be predictive of future recovery in the Indian population.
Around 10%–15% rates were noted for both maternal and fetal mortality. This is largely encouraging considering that maternal mortality rates of PPCM are known to vary between 7% and 50% worldwide. However, the mortality is still considerably higher than developed countries where rates of around 4% are reported.
This pooled analysis included data from seven studies reporting clinical features of PPCM in the Indian population. An incidence of 1 per 1340 live births was identified. Most patients presented in the postpartum period, and hypertensive disorders and anemia were commonly associated with the occurrence of PPCM. There was a high incidence of cardiogenic shock with comparable pregnancy outcomes in terms of maternal mortality. However, we feel that Indian data are inadequate and we need larger studies and possibly online databases for further delving into the microcosm of cardiac conditions in pregnancy.
Financial support and sponsorship
Conflicts of interest
The authors declare that they have no conflict of interest.
| References|| |
Prasad GS, Bhupali A, Prasad S, Patil AN, Deka Y. Peripartum cardiomyopathy – Case series. Indian Heart J 2014;66:223-6.
Binu AJ, Rajan SJ, Rathore S, Beck M, Regi A, Thomson VS, et al
. Peripartum cardiomyopathy: An analysis of clinical profiles and outcomes from a tertiary care centre in southern India. Obst Med 2020;13:1-6.
Joshi AV, Fonseca MN, Kharat-Kapote DS. A study of peripartum cardiomyopathy in a tertiary care centre in India. Int J Reprod Contracept Obstet Gynecol 2017;6:523-6.
Mishra TK, Swain S, Routray SN. Peripartum cardiomyopathy. Int J Gynaecol Obstet 2006;95:104-9.
Mandal D, Mandal S, Mukherjee D, Biswas SC, Maiti TK, Chattopadhaya N, et al
. Pregnancy and subsequent pregnancy outcomes in peripartum cardiomyopathy. J Obstet Gynaecol Res. 2011;37:222-7. doi: 10.1111/j.1447-0756.2010.01378.x. Epub 2010 Nov 28. PMID: 21114580.
Suri V, Aggarwal N, Kalpdev A, Chopra S, Sikka P, Vijayvergia R. Pregnancy with dilated and peripartum cardiomyopathy: Maternal and fetal outcome. Arch Gynecol Obstet 2013;287:195-9.
Pandit V, Shetty S, Kumar A, Sagir A. Incidence and outcome of peripartum cardiomyopathy from a tertiary hospital in South India. Trop Doct 2009;39:168-9.
Isogai T, Kamiya CA. Worldwide incidence of peripartum cardiomyopathy and overall maternal mortality. Int Heart J 2019;60:503-11.
Demakis JG, Rahimtoola SH, Sutton GC, Meadows WR, Szanto PB, Tobin JR, et al
. Natural course of peripartum cardiomyopathy. Circulation 1971;44:1053-61.
Elkayam U, Akhter MW, Singh H, Khan S, Bitar F, Hameed A, et al
. Pregnancy-associated cardiomyopathy: Clinical characteristics and a comparison between early and late presentation. Circulation 2005;111:2050-5.
Arany Z, Elkayam U. Peripartum cardiomyopathy. Circulation 2016;133:1397-409.
Wang M. Peripartum cardiomyopathy: Case reports. Perm J 2009;13:42-5.
Sieweke JT, Pfeffer TJ, Berliner D, König T, Hallbaum M, Napp LC, et al
. Cardiogenic shock complicating peripartum cardiomyopathy: Importance of early left ventricular unloading and bromocriptine therapy. Eur Heart J Acute Cardiovasc Care 2020;9:173-82.
Okeke T, Ezenyeaku C, Ikeako L. Peripartum cardiomyopathy. Ann Med Health Sci Res 2013;3:313-9.
] [Full text]
Kerpen K, Koutrolou-Sotiropoulou P, Zhu C, Yang J, Lyon JA, Lima FV, et al
. Disparities in death rates in women with peripartum cardiomyopathy between advanced and developing countries: A systematic review and meta-analysis. Arch Cardiovasc Dis 2019;112:187-98.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]