Peripartum Cardiomyopathy (PPCM)

Failing-heart goals - Avoid myocardial depression, maintain heart rate and sinus rhythm, keep afterload reduced but avoid hypotension (coronary perfusion), and manage volume tightly - this ventricle floods into pulmonary edema easily.

Neuraxial is usually preferred - A slowly titrated epidural for labor or cesarean reduces afterload and avoids the myocardial depression and swings of general anesthesia; maintain systemic vascular resistance carefully and treat hypotension promptly.

Uterotonics with caution - Give oxytocin slowly in low doses (a rapid bolus causes hypotension and tachycardia) and avoid ergometrine, whose vasoconstriction raises afterload dangerously.

Monitoring - Use invasive arterial monitoring and consider echocardiography for significant dysfunction; have vasopressors and inotropes ready.

Anticoagulation and thromboembolism - A low ejection fraction predisposes to thromboembolism and patients may be anticoagulated; time neuraxial techniques around anticoagulation per current ASRA guidance.

Team - Manage jointly with cardiology, obstetrics, and critical care, and plan disposition for the postpartum period.

A systolic heart failure - essentially a dilated cardiomyopathy - that develops in the last month of pregnancy or the months after delivery, without another identifiable cause. The left ventricle dilates and the ejection fraction falls, presenting with dyspnea, edema, arrhythmias, and sometimes cardiogenic shock or thromboembolism. Many recover ventricular function over months, but the peripartum period carries real risk of decompensation, and the physiology is that of a failing, volume-sensitive heart with low reserve superimposed on the demands of labor and delivery.