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Annals of Cardiovascular Diseases

Cite this article: Mbaye A, Ngaïde AA, Ndiaye Y, Dioum M, Ndiaye M, et al. (2016) Peripartum Cardiomyopathy: Management of 47 Black Women in a General Cardiology Department of Senegal. Ann Cardiovasc Dis 1(1): 1004.

*Corresponding authorAlassane Mbaye, Cardiology department of Grand-Yoff General Hospital; postal box: 3270, Dakar, Senegal, Tel: 00221-775660649; Email:

Submitted: 29 May 2016

Accepted: 18 June 2016

Published: 20 June 2016

Copyright© 2016 Mbaye et al.

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Keywords•Cardiomyopathy•Peripartum•Heart failure•Pregnancy

Review Article

Peripartum Cardiomyopathy: Management of 47 Black Women in a General Cardiology Department of SenegalA Mbaye1*, AA Ngaïde1, Y Ndiaye1, M Dioum3, M Ndiaye1, MM Ka1, I Kouame1, ND Gaye1, K Babaka1, JS Mingou2, F Aw2, SA Sarr2, M Bodian2, MB Ndiaye2, and A Kane11Department of Cardiology Grand-Yoff General Hospital, Senegal2Department of Cardiology, Aristide Le-Dantec Hospital, Senegal3Department of Cardiology, Fann Hospital, Senegal

Abstract

Introduction: Peripartum cardiomyopathy is a heart failure which occurs between the eighth month of pregnancy and five months after delivery without any earlier symptoms of heart disorder. We aimed to evaluate management and prognostic factors at cardiology department in Senegal.

Methods: This is a cross-sectional descriptive study, conducted between January 2006 and June 2015 at the cardiology department of the Grand-Yoff general hospital. We have included women who were healthy before and who suffered from heart failure between the last month of pregnancy and 5 months after delivery. Diagnostic and therapeutic aspects have been studied and the prognostic factors evaluated at 6 months in those with no remission of symptoms. The data were analyzed using Excel software with a significance level set at p < 0.05.

Results: We identified 47 patients, i.e. a prevalence of 0.8% with an average age of 29.26 years. The disease occurred in postpartum period in 87.3% of cases, 29% in twin pregnancy, and 70.2% in multiparous. It often turned out to be congestive heart failure (78.7%). Echocardiography constantly showed hypokinetic cardiomyopathy with average left ventricular ejection fraction (LVEF) of 30.84%. At 6 months, clinical remission was observed in 27 patients (57.4%), complications in 7 (14.9%) and death in 4 (8.5%) of them. The factors of poor prognosis were LVEF < 27% (p = 0.024) and diastolic diameter of the left ventricle > 63 mm (p = 0.037).

Conclusion: In Senegal, peripartum cardiomyopathy appears similar to other reported studies and occurs more frequently in older, multiparous women. Prognosis is worse when the left ventricle function plummets the greatest with severely dilated ventricle.

INTRODUCTIONPeripartum cardiomyopathy (PPCM) is a heart disease of

unclear etiology that associated with pregnancy [1,2]. PPCM is a major cause of heart failure (HF) and cardiovascular mortality among women of child-bearing age [1,3]. Its initial definition was based on the combination of the four following criteria: (1) heart failure (HF) occurring in the last month of pregnancy or within 5 months of delivery; (2) absence of an identifiable cause of cardiac failure other than pregnancy, (3) absence of recognizable heart disease before the last month of pregnancy and (4) left ventricular

systolic dysfunction (LVSD) with left ventricular ejection fraction (LVEF) < 45% by echocardiography, fractional shortening < 30% or both [2,4-6]. The Heart Failure Association of the European Society of Cardiology Working Group on PPCM has defined it as an idiopathic cardiomyopathy presenting with HF secondary to LVSD towards the end of pregnancy or in the months following delivery, when no other cause of HF is found [4,5,7]. PPCM remains a diagnostic of exlusion. It was classified as dilated non-family and non-genetic, pregnancy-related cardiomyopathy [4]. Etiology is complex and evolution remains unpredictable with a high risk of recurrence in subsequent pregnancies. This condition

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is variously reported in Africa [8-10]. Our aim was to assess the prevalence of PPCM, to study its management and its prognostic factors at cardiology departement in Senegal.

MATERIALS AND METHODSType, framework and period of study

This is a transversal and descriptive study conducted at the cardiology department of Grand-Yoff general hospital in Dakar, Senegal, between 1 January 2006 and 30 June 2015. This is a national reference centre in terms of heart disease and is located in the Senegalese capital suburb. It provides care, research and training for doctoral students and physicians in specialization.

Inclusion criteria

We included women with the following criteria:

Heart failure occurring between the last month of pregnancy and 5 months after childbirth, in women who were previously healthy;

LVEF ≤ 45% and/or factional shortening ≤ 30% by echocardiography;

Unknown previous heart disease;

Admittance to the cardiology department of Grand-Yoff General Hospital in the study period.

Exclusion and non-inclusion criteria

Presence of a pre-existing heart failure which could evidence the disease; Observable severe anemia with hemoglobin level ≤ 7 g/dl; Lost or unusable patients records.

Course of the survey and parameters studied

We have identified the patients’ records that met the inclusion criteria described above. Data were collected from the register of hospitalization and outpatient visits, through a form designed for this purpose. The parameters studied were the following: socio-demographic, medical and obstetric history (number of pregnancies, twining), the time to onset of symptoms compared to the end of pregnancy and childbirth, symptoms, physical signs, paraclinical signs, and therapeutic and evolutionary aspects. The data of evolution were analyzed under hospitalization and at 6-months follow-up to investigate remission or not of clinical signs, advent or not of complications or death. Thus, the patients were divided into 2 groups at the 6-month follow up: Group 1 (patients in clinical remisson) and Group 2 (symptomatic patients). No patients received coronary angiography.

Data processing

Data were analyzed using the Epi Info software. The characteristics of patients were expressed as of the mean ± standard deviation. Parametric tests of Student and Chi2 were used to compare the two groups from the epidemiological, clinical and echocardiographic aspects to analyze the prognostic factors. The significance threshold was chosen for a p-value ˂ 0.05.

RESULTSDuring our study period, 5621 patients were admitted in the

care unit, of which 47 patients for PPCM. Prevalence of PPCM was

0.8% with an annual incidence of 4.95. The average age of patients was 29.26% ± 8.26 years and 55.3% of them were aged under 30 years. A low socio-economic level was noted in 70% of cases. 29% of pregnancies turned out to be twins. Multiparity was noted in 70.2% of women and 26% had more than 4 pregnancies (Figure 1). The disease occurred in postpartum period in 87.3% of cases, specifically in the first months in 61.7%. In 37 cases (78.7%) patients had congestive heart failure and in 10 cases (21.3%), they suffered from isolated left ventricular failure. Functional signs were dominated by dyspnea (100%), cough (68.1%), chest pain (27.7%), hemoptysis (14,9%) and palpitations (10,6%). Physical signs are summarized on the Table (1). The average systolic blood pressure was 119 ± 34 mmHg (60-140 mmHg). The average diastolic blood pressure was 84.4 mmHg (60-130 mmHg). Blood pressure was normal in 44 cases and 3 patients had hypertension. Frontal chest x-ray showed in all cases global cardiomegaly and signs of venous hypertension. All patients had a sinus rhythm on the electrocardiogram with the presence of isolated extrasystole in 2 patients. Left atrial enlargement was found in 85.1 % of cases and left ventricular in 61.7%. Secondary repolarization disorders were recorded on 24 graphs (51%). Echocardiography showed in all patients a hypokinetic cardiomyopathy associated with reduced systolic function parameters of left ventricular (LV). The mean LVEF was 30.84%. LV dilation was observed in 36 cases (76.6%) and mean diastolic LV diameter was 60.66 ± 6.59 mm with a range of 50 mm and 79 mm. The average systolic LV diameter was 51.60 ± 6.59 mm with a range of 31.7 mm and 68 mm. The average diastolic diameter of the right ventricle was 29.34 ± 6.92 mm with a range of 11 mm and 41 mm. Dilatation of the left atrium was observed in 21 patients with a mean anteroposterior diameter of 41.70 ± 7.37 mm. Furthermore, there was a minimal pericardial effusion of low to average abundance in 18 cases (38.3%), intraluminal thrombus in 5 cases Figure (2) and spontaneous contrast in 4 cases. Most

Figure 1 Distribution of patients according to the parity (n = 47).

Table 1: Physical signs (n = 47).

Signsa Effectifs Fréquences (%)

Tachycardia 39 83

Arythmia 2 4,25

Gallop rythm 40 85,1

Mitral systolic murmur 20 42,6

Crackles 30 63,8

Hepatomegaly 34 72,3

Ascite 15 31,9

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frequent laboratory abnormalities were CRP elevation in 25 cases (53.2%). The mean CRP level was 48 mg/L with a range of 6 and 192 mg/L. Hyperleucytosis was noted in 14 patients (31.8%). Mean WBC count of 8,971 per mm3 with a range of 3,500 and 21,700 WGC per mm3. Moderate anemia was found in 34 patients with an average hemoglobin level of 10.9 g/dl. The red blood cells distribution width was not available in our laboratory. As for treatment, strict rest and salt restriction were observed in all patients. In the acute phase, loop diuretics (Furosemide) and Spirinolactone were prescribed in such cases, nitrates in 66%, angiotensin-converting enzyme in 95.7%. On leaving the hospital, 49% of patients had a beta-blocker and 81% oral anticoagulant with vitamin K antagonist (VKA). Similarly, contraception has been prescribed in 22 cases. No patient received treatment with immunosuppressive or Bromocriptine. The hospital evolution was favorable in 38 patients (81%). Complications were noted in 7 patients with, pulmonary embolism (2 cases), deep veinous thrombosis of the lower limb (1 case), ischemic stroke (3 cases) and atrial tachycardia (1 case). Two patients died of cardiogenic shock and pulmonary embolism during hospitalization. In 6th month follow-up, 27 patients (57.4%) were in clinical remission while 5 (10.6%) remained symptomatic and 2 died. At 3 years, 2 patients relapsed during another pregnancy. The factors of poor prognosis associated with absence of clinical remission were LVEF 63 mm (p = 0.037). Patients with isolated left ventricular failure (p = 0.04), were more likely to have clinical remission (Table 2).

DISCUSSIONCertainly, this study has limitations related to its retrospective

nature. However, in the absence of multi-center study, we will still compare our results with those reported in a similar context. The epidemiological profile of the CMPP is largely unknown and the incidence of the disease varies according to geographical regions, ethnic group, socio-economic factors and the criteria for inclusion in studies [1]. The data usually come from Africa, Haiti and the United States of America (USA). A US study reported an incidence of 0.18 per 1000 deliveries [1,11]. The incidence is higher in Haiti and Africa than in the USA [1]. Genetic factors are discussed with the disparities between geographical areas and the greater frequency of PPCM appears in the black women, especially in the

USA, among African American [1,11]. The pathogenesis of PPCM is complex. It involves factors such as low levels of selenium, viral infections, cytokines, inflammation, autoimmune reactions, pathologic response to hemodynamic stress and unbalanced oxidative stress [1,7]. Several factors are associated with PPCM as older maternal age, multiparity, multi-fetal pregnancy (twins), prior toxin esposure (cocaine), use of certain medications to preventing premature labor, African descent and high blood pressure [2]. Bello et al., reported a prevalence of pre-eclampsia, hypertensive disorders and multiple gestations in women with PPCM higher than that the general population [12]. Multiparity has been reported, as noted in our patients in several studies [1,10]. Similarly, twinning risk factor found by other authors [10]. In a study conducted in the USA, increase in the incidence of PPCM in 1990-1993 to 2000-2002 was noted and attributable to a rise in maternal age and increase in multifetal pregnancies owing to access to reproduc tive techniques, or possibly improved recognition and diagnosis of the disease [1,7]. A low socioeconomic level was found in studies in Africa [10]. More recent experimental studies suggest a critical role of deregulation of angiogenesis after pregnancy with increased oxidative stress causing increased degradation of the prolactin, as part of the development of PPCM. Other studies show the increase of anti-angiogenic factors in late pregnancy probably constituting a substrate on which any infectious or inflammatory impairment or abnormality could trigger latent left ventricular dysfunction [5,7,13]. Hilfiker-Kleiner et al., showed that female mice with a cardiomyocyte specific deletion of STAT3 protein develop PPCM

Figure 2 Bidimensional echocardiography, apical for 4-chamber view showing a thrombus in the apical left ventricle (red arrow).

Table 2 : Analysis of pronostic factors at 6-month follow up (n = 42).

Parametersa

Patients with clinical remission (n=27)

Patients without clinical remission (n=15)

P

Age (years) 29,3 ± 76 34,4 ± 80 0,196

Twin pregnancy (%) 40,7% 00% 0,067

Multiparity (%) 66,6% 80% 0,096

Tachycardia (%) 85,2% 100% 0,327Cardio-vascular collapse (%) 3,7% 00% 0,07

Congestive heart failure (%) 74,1% 100% 0,723

Isolated left ventricle heart failure (%) 25,9% 00% 0,042*

LVSD (mm) 48,9 ± 18,4 55,3 ± 5,0 0,050

LVDD (mm) 58,0 ± 21,0 63,3 ± 4,6 0,037*Fractional shortening (%) 15,8 ± 7,2 12 ± 3,0 0,166

LVEF (%) 32,1 ± 9,1 27,4 ± 5,7 0,024*Diameter of left atrium (mm) 39,4 ± 30,9 45,76 ± 6,04 0,072

Right ventricle diameter 28,7 ± 13,9 32,46 ± 4,43 0,294

Cardiac thrombosis (%) 22,2% 00 % 0,061

LVSD : Left Ventricle Systlic Diameter ; LVDD : Left Ventricle Diastolic Diameter ; LVEF : Left Ventricle Ejection Fraction. (*) : significant statistical difference

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[14]. Thus the clinical expression of the disease appears uniquely. In fact, in our patients, as in the literature, PPCM mostly presents an overall picture of congestive heart failure [3,15]. Biologically, outside the disorders related to heart failure, inflammatory signs are described in the CMPP. In fact, Sliwa et al., reported significant increase plasma markers of inflammation that is correlated to the expansion of the left ventricle and the decrease in its ejection fraction [16]. Systolic left ventricular dysfunction is constant, but, dilatation of the heart chambers, though frequent, is not constant as confirmed by our study [17]. These cardiac wall motion abnormalities promote the formation of ventricular thrombosis as in 9 of our patients. Similar findings have been noted in other studies [8,9]. Echocardiography is essential for the diagnosis by showing the left ventricular systolic dysfunction with or without dilatation of the left ventricle or the presence of intracardiac thrombosis [3,8]. Thrombosis exposes these patients to the risk of systemic embolism including stroke which affected 3 of our patients [8]. This situation can cause complications and increase lethality during PPCM [3]. More than half of the deaths occurred, according to some authors, in six months postpartum [3]. Retrospective analyzes indicate that the clinical course and prognosis of this disease are directly related to the normalization of the size of the heart chambers [19]. In fact, patients who normalize LVEF have more chances of recovery [18,19]. There is a risk of recurrence even after remission and patients should be advised on the risk of subsequent pregnancy. Patients with PPCM should informed about contraceptive options and they should benefit from the safest and most effective contraceptive method [9,15]. In developing countries as Senegal, this raises the problem of contraception that should be offered to these women prior to hospital discharge. Few of our patients could have access to gynecological consultation for contraception. Some criteria are predictive of poor prognosis. Older maternal age , multiparity , severe left ventricular systolic dysfunction and delayed diagnosis are poor prognostic fateurs according some authors [3].We identified two factors worsing prognosis in our patients. Treatment of PPCM is similar to that of heart failure based on allowing rest in the acute phase, the use of diuretics, angiotensin blockers and beta-blockers [6,20]. If heart failure occurs before term, the decision to perform premature delivery will be discussed case by case depending on the severity of left ventricular dysfunction, the initial response to treatment and possible fetal distress [6]. Vaginal delivery is always preferable if the patient is haemodynamically stable [7]. However, angiotensin blockers are not recommended during pregnancy and vaginal extraction of the fetus should be done very quickly if hemodynamics is stable, and by caesarean section if this is not the case [6]. Bromocriptine, an agonist of dopamine D2 receptors, was also tested in the treatment of PPCM [13,21]. In a single-center study on a small number performed in South Africa, Sliwa et al., showed the interest of Bromocriptine in the treatment of severe acute PPCM [13]. Thus, the addition of this molecule to the standard treatment of heart failure appeared to improve left ventricular ejection fraction and the incidence of the composite endpoint. However, such treatment has to be confirmed by multi-center blind studies by the authors [13].

CONCLUSIONPeripartum cardiomyopathy is a serious heart condition that

affects the young woman of child-birth previously healthy. In Senegal, it appears similar to other reported studies and occurs more frequently in older, multiparous women, usually in the first month after delivery. Prognosis is worse when the left ventricle function plummets the greatest with severely dilated ventricle and compromises the recovery.

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Mbaye A, Ngaïde AA, Ndiaye Y, Dioum M, Ndiaye M, et al. (2016) Peripartum Cardiomyopathy: Management of 47 Black Women in a General Cardiology Depart-ment of Senegal. Ann Cardiovasc Dis 1(1): 1004.

Cite this article

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Peripartum Cardiomyopathy: Management of 47 Black Women in a General Cardiology Department of SenegaAbstractIntroductionMaterials and MethodsType, framework and period of studyInclusion criteriaExclusion and non-inclusion criteriaCourse of the survey and parameters studiedData processing

ResultsDiscussionConclusionReferencesFigure 1Table 1Figure 2Table 2