European Journal of Heart Failure (2017)

doi:10.1002/ejhf.808

Outcome of subsequent pregnancies

in patients with a history of peripartum
cardiomyopathy
Denise Hilfiker-Kleiner1†, Arash Haghikia1†, David Masuko2, Justus Nonhoff1,
Dominik Held1, Elena Libhaber3, Mark C. Petrie4, Niki L. Walker4, Edith Podewski1,
Dominik Berliner1, Johann Bauersachs1†, and Karen Sliwa2,3†*
1 Department of Cardiology and Angiology, Medical School Hannover, Germany; 2 Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Faculty of
Health Sciences, University of Cape Town, South Africa; 3 School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa; and 4 University of Glasgow
and West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, Scotland

Received 3 November 2016; revised 6 February 2017; accepted 6 February 2017

Aims Subsequent pregnancies (SSPs) in patients with peripartum cardiomyopathy (PPCM) have a high risk of heart failure
relapse. We report on outcome of SSPs in PPCM patients in Germany, Scotland, and South Africa.
.....................................................................................................................................................................
Methods Among 34 PPCM patients with a SSP, pregnancy ended prematurely in four patients while it was full-term in 30.
and results Overall relapse rate [left ventricular ejection fraction, LVEF <50% or death after at least 6-month follow-up] was 56%
with 12% (4/34) mortality. Relapse of PPCM after SSP was not associated with differences in parity, twin pregnancy,
gestational hypertension, or smoking. Persistently reduced LVEF (<50%) before entering SSP was present in 47% of
patients while full recovery (LVEF ≥50%) was present in 53%. The majority of patients entering SSP with persistently
reduced LVEF were of African ethnicity (75%). Persistently reduced LVEF before SSP was associated with higher
mortality (25% vs. 0%) and lower rate of full recovery at follow-up. Patients obtaining standard therapy for heart
failure and bromocriptine immediately after delivery displayed significantly better LVEF at follow-up and a higher rate
of full recovery with no patient dying compared with patients obtaining standard therapy for heart failure alone. This
was independent of African or Caucasian race.
.....................................................................................................................................................................
Conclusion Full recovery of LVEF before SSP was associated with lower mortality and better cardiac function at follow-up.
Addition of bromocriptine to standard therapy for heart failure immediately after delivery was safe and seemed to
be associated with a better outcome of SSP in African and Caucasian patients.
..........................................................................................................
Keywords Peripartum cardiomyopathy • Subsequent pregnancy • Biomarker • Therapy

Introduction PPCM patients bear a high risk for relapse especially if patients
...........................

Peripartum cardiomyopathy (PPCM) is a major cause of pregnancy-
induced heart failure and is associated with high morbidity and
mortality.1 – 5 The pathophysiology still remains unclear, with mul-
tiple factors likely contributing to and driving progression.
One of the most frequently asked questions by patients or treat-
ing physicians concerns the health risk of subsequent pregnancies
(SSPs). The literature is scarce but clearly indicates that SSPs in
did not recover normal cardiac function.6 – 9 The two largest stud-
ies analysing SSPs in PPCM patients (mostly retrospective studies
in the USA) observed relapse of left ventricular (LV) dysfunction
and/or worsening of heart failure symptoms in about 30% of all
cases.7 – 9 A general review of published cases states that the risk
for relapse is high in SSP, especially in women who have not recov-
ered LV ejection fraction (LVEF) before entering SSP, and reports
that about 20% of PPCM patients entering SSP with recovered LVEF

*Corresponding author. Tel: +27 21 406 6457, Fax: +27 21 447 8789, Email: Karen.sliwa-hahnle@uct.ac.za
† These authors contributed equally.

© 2017 The Authors

European Journal of Heart Failure © 2017 European Society of Cardiology
2 D. Hilfiker-Kleiner et al.

may face a relapse.6 In addition, the review points out that PPCM index PPCM at the time of diagnosis, before the SSP, during SSP (sec-

........................................................................................................................................................................
patients entering SSP with unrecovered LV function have an almost ond or third trimester), after delivery (while still admitted in hospital),
50% risk of LV deterioration during the SSP.6 The potential fatal and after at least 6-month follow-up (between 6 and 12 months post-
partum). Three patients were excluded: one died during pregnancy,
outcome after SSP not only affects the patient herself but will have
one after delivery, and one was lost to follow-up after delivery.
also a strong social impact on the newborn and any other pre-
viously born living children who are dependent on their mother’s
care. Therefore, management of PPCM patients must involve coun- Drug treatment
selling on risks of additional pregnancies and in this regard also on If STHF was applied, beta-blockers and in most patients ACE-inhibitors
the appropriate use of contraceptive agents.10 To date, the manage- or ARB (decided by the treating physician) treatment started immedi-
ment of SSP in PPCM patients is only briefly addressed in current ately after SSP according to the haemodynamic status of the patient, as
guidelines on pregnancy-related heart diseases.11 Therefore, data recommended by the ESC guidelines.11 Treatment during pregnancy
must be collected on optimal management of SSP if a PPCM patient with beta-blockers was according to the ESC guidelines for preg-
becomes pregnant again, whether planned or accidentally. nant patients with cardiomyopathies.11 Bromocriptine treatment was
administered according to the protocol published in our pilot study13
Our previous research suggested that the nursing hormone pro-
to efficiently suppress prolactin by 2.5 mg to 5 mg daily for at least
lactin, which is highly elevated during delivery, and periodically in
4 weeks, in addition to STHF. Bromocriptine treatment was also started
nursing mothers, is a key player in the pathophysiology of PPCM. immediately after delivery. Patients who did not underwent this treat-
We showed that additional factors such as oxidative stress pro- ment protocol but received STHF, according to the guidelines,11 were
mote the cleavage of prolactin in an antiangiogenic 16 kDa pro- defined as STHF group.
lactin fragment that is causally involved in PPCM.12 Furthermore,
experimental studies in mice and first clinical pilot studies suggest
a beneficial effect of the prolactin blocker bromocriptine (BR) to
Analysis of outcome
heal acute PPCM or prevent relapse after SSP.12,13 Patients were classified with regard to recovery according to the
In order to evaluate the influence of management and drug 2016 ESC guidelines defining preserved LV function as LVEF >49%.14
Accordingly, patients were defined as entering SSP with fully recovered
treatment on the outcome of SSP in PPCM, we analysed SSPs in 34
function if LVEF was ≥50% and persistently reduced LV function if LVEF
PPCM patients collected in South Africa, Germany, and Scotland,
was <50% either measured before SSP or assessed within the first
who were diagnosed according to the revised definition of the
trimester of the SSP. As for the recovery state at follow-up of SSP,
Heart Failure Association of the European Society of Cardiology patients who showed an LVEF ≥50% were classified as fully recovered
(ESC).5 We could confirm the higher risk for persisting heart fail- from PPCM and patients with LVEF <50% or those who died during
ure or death in PPCM patients entering SSP with LV function that SSP or after SSP were classified as not recovered or relapse of PPCM
was not fully recovered and observed a potential beneficial effect of after SSP. LVEF after delivery was always measured within the first week
standard therapy for heart failure [STHF; beta-blocker and in most after delivery when patients had already obtained medication.
patients also angiotensin-converting enzyme (ACE)-inhibitors/
angiotensin receptor blocker (ARB)] combined with BR started
immediately after delivery to prevent a relapse after SSP.
Statistical analysis
Database management and statistical analyses were performed with
SAS software, version 9.2 statistical program (SAS, Institute Inc., Cary,
NC, USA). Continuous data were expressed as mean ± SD or median
Methods and range. Comparison of means and proportions between subgroups
at baseline were performed by independent t-test and chi-square statis-
Data collection tics, or Fisher exact test, respectively, where necessary. Wilcoxon
Our local Ethics Committees approved this study. Subsequent preg- rank-sum test was used if data were not normally distributed. Signifi-
nancies in 34 patients with clearly diagnosed index PPCM were treated cance was assumed at a two-sided value of P < 0.05.
and/or managed either at university hospitals, in tertiary hospitals,
or by cardiologists in private practice in South Africa, Germany, or
Scotland, between 2005 and 2015. All 34 PPCM patients with SSP Results
matched the diagnostic criteria for PPCM at their index PPCM (LVEF
≤45%) and had absence of previously known cardiomyopathy.5 All Age, gravidity, parity and cardiac
patients provided written informed consent. Minimal requirement for
enrolment was fulfilling the criteria for the diagnosis of PPCM,5 includ-
function at index peripartum
ing availability of baseline LVEF at the index pregnancy and LVEF after cardiomyopathy and at delivery
subsequent pregnancy. Unfortunately, not all patients agreed to pro- of subsequent pregnancy
vide additional clinical data and this is the reason why not all other data
The 34 PPCM patients presented with a mean LVEF of 31 ± 7% at
sets are complete in this registry. Clinical assessment such as onset
of symptoms and signs during first presentation, echocardiographic index pregnancy and a mean LVEF of 50 ± 10% before SSP. The
analyses, diseases in pregnancy and mode of delivery from index PPCM median parity at SSP in all 34 patients was 3 (range 1–6). In
and SSP were obtained from the patient, the referring physician, and four patients, pregnancy ended prematurely (one patient died in
by examining the obstetric cards and medical records. Clinical and pregnancy and three had an abortion in the first trimester) and 30
laboratory assessments were performed in 31 patients with confirmed patients had full-term pregnancies. In order to analyse the outcome

© 2017 The Authors

European Journal of Heart Failure © 2017 European Society of Cardiology
PPCM and subsequent pregnancy 3

after SSP we followed patients for at least 6 months (6–68 months). the effect of LV function before SSP in our group, we divided

..............................................................................................
Follow-up data after delivery were available for 32 patients as one patients into those who displayed full recovery (LVEF ≥50%)
patient had died during SSP and one patient was lost to follow-up. and those who had reduced LVEF (<50%) when entering SSP.
The mean follow-up LVEF was 47 ± 13%. Recovered PPCM (LVEF Full recovery from PPCM before SSP was observed in 18/34
≥50%) at follow-up was observed in 43% (15/32) of patients, patients, while persistent reduced LV function was present in 16/34
while adverse outcome (death, n = 3) or persistently reduced LVEF patients (Table 1). It was found that age, mode of delivery, rate
(<50%) was present in 57% (17/32). The overall mortality rate in of miscarriage/abortion, pregnancy associated hypertension, or
this collective of PPCM patients with SSP was 12% (4/34). the distribution of African and Caucasian patients did not differ
between groups (Table 1). However, among all African patients
Left ventricular function at index (n = 20) the percentage of patients entering SSP with persistently
reduced LVEF was higher (12/20, 60%) compared with Caucasian
peripartum cardiomyopathy pregnancy
patients (4/14, 29%). There was no difference in the parity of
complications and outcome, and mode African and Caucasian PPCM patients (African median 3, range
of delivery of subsequent pregnancies 2–6; Caucasian median 3, range 2–6) but parity was significantly
In the 32 patients with follow-up data, those with recovery at higher in all patients entering SSP with unrecovered LV function
follow-up displayed a similar LVEF at index PPCM to that of patients (Table 1). Beta-blocker and ACE-inhibitors/ARB after SSP were
with no recovery after SSP (recovered SSP, LVEF at index PPCM: applied in all 15 patients entering SSP with persistent reduced LV
32 ± 5%, n = 15 vs. unrecovered SSP; index PPCM: 31 ± 6, n = 17, function that survived the SSP. In the patients with fully recovered
P = 0.78). In addition, neither age, gravity, parity, pregnancy out- LVEF before SSP, 15/18 received beta-blocker and 12/18 received
come (abortion, twin pregnancy), pregnancy-associated hyperten- ACE-inhibitor/ARB after SSP. During SSP, one patient of African
sion, smoking, or mode of delivery were different between patients origin died and three additional patients (two Africans and one
with or without recovery after SSP. Caucasian woman) died during follow-up of SSP. All four patients
had entered SSP with persistently reduced LV function (LVEF
before SSP of the patient who died during SSP was 26% and in
Clinical presentation and outcome the three patients who died during follow-up of SSP LVEF was
of subsequent pregnancies in patients 48%, 36%, and 35%) showing that this group had a significantly
who entered subsequent pregnancies higher mortality compared with patients entering SSP with fully
recovered LV function (Table 1). Among the 16 patients entering
with recovered versus not recovered left
SSP with unrecovered LV function, one Caucasian patient was lost
ventricular function to follow-up. In the 15 remaining patients of this group, mean LVEF
Previous reports suggested that recovery of LV function before early after delivery was significantly lower compared with the 17
SSP is associated with a better outcome of SSP.7 – 9 To analyse patients entering SSP with fully recovered LV function (Table 1).

Table 1 Clinical presentation and outcome of subsequent pregnancies (SSPs) in patients entering SSP with
persistently reduced (LVEF <50%) or fully recovered left ventricular function (LVEF ≥50%)

LVEF <50% (n = 16) LVEF ≥50% (n = 18) P-value

...........................................................................................................................................
Age at index PPCM, years (mean ± SD) 27 ± 7 (16/16) 29 ± 5 (18/18) 0.50
Age at SSP, years (mean ± SD) 30 ± 7 (16/16) 31 ± 5 (17/18) 0.59
Gravida SSP, median (range) 3 (2–5) (16/16) 3 (2–5) (17/18) 0.60
Parity SSP, median (range) 3 (2–6) (16/16) 2.5 (1–4) (18/18) 0.04
Twin pregnancy 0% (0/16) 11% (2/18) 0.49
Caesarean section 40% (6/15) 24% (4/17) 0.45
Abortion, miscarriage, still birth 7% (1/15) 17% (3/18) 0.60
Pregnancy-induced hypertensive disorders 6% (1/16) 5.5% (1/18) 1.00
African origin 75% (12/16) 44% (8/18) 0.09
LVEF (%) at diagnosis of index PPCM (mean ± SD) 31 ± 7 (16/16) 32 ± 8 (18/18) 0.68
LVEF (%) before SSP (mean ± SD) 42 ± 6 (16/16) 58 ± 5 (18/18) <0.0001
LVEF (%) after delivery of SSP (mean ± SD) 43 ± 11 (15/16) 51 ± 13 (17/18) 0.022
LVEF (%) SSP follow-up (mean ± SD) 43 ± 15 (12/16) 50 ± 13 (17/18) 0.24
Full recovery from PPCM after SSP 31% (5/16) 56% (10/17) 0.28
Death 25% (4/16) 0% (0/18) 0.04

LVEF, left ventricular ejection fraction; PPCM, peripartum cardiomyopathy.

Patients were divided into a group entering SSP with persistently reduced leff ventricular function (LVEF <50%) and a group with fully recovered left ventricular function (LVEF
≥50%) before SSP. The exact number of data sets analysed for each parameter is provided after each value. In patients with SSP, LVEF was measured in the first few days after
delivery.

© 2017 The Authors

European Journal of Heart Failure © 2017 European Society of Cardiology
4 D. Hilfiker-Kleiner et al.

At follow-up (at least 6 months after delivery), the proportion of patients in the STHF group (Table 2). In addition, no patient in the

.......................................................................................................
patients with stable full recovery (LVEF ≥50%) tended to be higher STHF + BR group died during follow-up of SSP, while two patients
in patients entering SSP with fully recovered LV function compared died in the STHF group.
with those entering SSP with persistently reduced LVEF. However,
the difference was not significant (Table 1).
Discussion
Outcome of patients receiving standard An important component of the care for women with PPCM is the
therapy for heart failure alone or discussion of the risk of a relapse during or after a SSP. Previous
studies suggest that some degree of cardiac dysfunction recurs in
with addition of bromocriptine
most PPCM patients in the postpartum phase of an SSP, with a
immediately after delivery of subsequent higher risk for adverse outcome when LV structure and function
pregnancy had not completely recovered before SSP.2,7,9
Medical records were available for 30 of the 34 patients. Of these, Here we report data from PPCM patients with SSPs followed
21 patients were given beta-blocker therapy whereas eight patients prospectively at three university hospitals in South Africa, Ger-
did not receive beta-blockers during pregnancy. many, and Scotland. We observed that despite the high risk of a
After delivery, all 30 patients received beta-blocker therapy and relapse of heart failure, half of the patients presenting with an SSP
25 received ACE-inhibitors/ARB, defined as STHF. Of these, 21 in our study were entering it with LV function not fully recovered.
patients received STHF and BR (which was started immediately Indeed, these patients had a substantially higher risk of a fatal
after delivery) and nine received STHF alone. No significant dif- outcome of SSP as all patients who died during or after SSP in
ferences were observed between the two groups with regard to the present study had entered the SSP with a LVEF that was not
gravida, parity, African race, LVEF at index PPCM, or LVEF before fully recovered. Moreover, persistently reduced LV function before
SSP (Table 2). In addition, a comparable proportion of patients in entering SSP was associated with lower cardiac function in the
both groups entered SSP with unrecovered cardiac function (LVEF early phase after SSP delivery and a lower chance for full recovery
<50%) and received beta-blockers (100%) and ACE-inhibitors/ARB during follow-up. However, even in patients entering SSP with fully
(17/21 in the STHF + BR group and 8/9 in the STHF group, as recovered cardiac function, stable full recovery at follow-up of SSP
decided by the treating physician). The STHF + BR group displayed was only observed in 56%, showing that PPCM patients with fully
a trend to older age at SSP. Moreover, they showed a trend to bet- recovered LV function also have a substantial risk for relapse in SSP.
ter LVEF in the first week after delivery, with significantly better It has been reported that women of African ethnicity may have
LVEF at follow-up of SSP compared with the group treated with a poorer outcome of PPCM.15 We found that the prevalence of
STHF alone (Table 2). The time-course of individual LVEF before patients entering SSP with persistently reduced LVEF was higher
SSP, after delivery, and at follow-up of SSP in patients treated with among patients of African ethnicity. In addition, three out of the
STHF alone or with STHF + BR is depicted in Figure 1. Moreover, four patients who died during or after SSP were African women,
significantly more patients in the STHF + BR group displayed full suggesting that they may indeed have a higher risk of a fatal
recovery from PPCM with LVEF ≥50% at follow-up compared with outcome of SSP.

Table 2 Comparison of cardiac and clinical parameters in patients receiving standard therapy for heart failure alone
or with addition of bromocriptine

Variables STHF + BR group (n = 21) STHF group (n = 9) P-value

...........................................................................................................................................
Age at SSP (years) (mean ± SD) 31.6 ± 4.6 26.7 ± 8.9 (9/9) 0.07
Gravida median (range) 3 (2–5) 3 (3–4) (8/9) 0.31
Parity median (range) 3 (1–6) 3 (2–6) (9/9) 0.56
African origin 57% (12/21) 44% (4/9) 0.69
LVEF (%) at index PPCM (mean ± SD) 32 ± 8 (21/21) 31 ± 7 (9/9) 0.89
LVEF (%) before SSP (mean ± SD) 51 ± 9 (21/21) 48 ± 11 (9/9) 0.35
LVEF ≥50% prior SSP 57% (12/21) 33% (3/9) 0.43
LVEF (%) after delivery of SSP (mean ± SD) 51 ± 9 (21/21) 38 ± 16 (9/9) 0.07
LVEF (%) at follow-up of SSP (mean ± SD) 51 ± 11 (21/21) 35 ± 14 (6/9)* 0.02
Full recovery from PPCM after SSP (LVEF ≥50%) 62% (13/21) 11% (1/8) 0.017
Beta-blocker 100% (21/21) 100% (9/9) 1.00

BR, bromocriptine; LVEF, left ventricular ejection fraction; PPCM, peripartum cardiomyopathy; SSP, subsequent pregnancy; STHF, standard therapy for heart failure (beta-blockers
and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers).
LVEF early after delivery of SSP was measured in the first few days after delivery before discharge, when medical treatment had already started. Follow-up LVEF after SSP was
analysed at least 6 months after delivery of SSP.
* Two patients died and one was lost to follow-up.

© 2017 The Authors

European Journal of Heart Failure © 2017 European Society of Cardiology
PPCM and subsequent pregnancy 5

(a)
80
70

Ejection fraction (%)

60
50
40
30
20
10
0
prior SSP after SSP delivery SSP follow-up

(b) 80
70
Ejection fraction (%)

60
50
40
30
*
20
*
10
0
prior SSP after SSP delivery SSP follow-up

Figure 1 Time-course of left ventricular ejection fraction (LVEF), before subsequent pregnancy (SSP), early after SSP delivery and at SSP
follow-up (>6 months) in patients with SSP. (a) Time-course of individual LVEF in patients treated with standard therapy for heart failure +
bromocriptine (BR) immediately after delivery of SSP (n = 21). (b) Time course of individual LVEF in patients treated with standard therapy for
heart failure alone after delivery of SSP (n = 9). *, patients who died after delivery and during follow-up of SSP.

In contrast, clinical conditions such as age, gravida, para, twin cardiac function at follow-up in patients receiving STHF + BR com-
............................................................................

pregnancy, hypertension in pregnancy, and/or smoking did not differ pared with patients receiving STHF alone. Moreover, no patient
between patients with fully recovered cardiac function after SSP in the STHF + BR group died, while two patients in the STHF
and those who remained in heart failure or died, suggesting that group died during follow-up, suggesting that this combination ther-
these factors do not have a substantial impact on SSP outcome. apy may indeed prevent relapse of PPCM and has beneficial effects
Guidelines on the management of cardiovascular disease in when started as early as possible after delivery. However, the num-
pregnancy11 suggest that patients with existing or previous ber of patients was small and additional information is required
cardiomyopathies may receive beta-blockers during pregnancy. (for example from the EURObservational Research Programme)
In the present study, the majority of patients were treated to achieve more conclusive data.16
with beta-blocker during SSP. However, whether this was ben-
eficial or not could not be evaluated because the number
of patients analysed was too small to draw any conclusion.
Future observations, for example deriving from the international Conclusion
PPCM registry of the EURObservational Research Programme All PPCM patients should be counselled regarding the risk of wors-
(http://www.escardio.org/Guidelines-&-Education/Trials-and- ening heart failure, and even death in SSP, as the risk is substantial
Registries/Observational-registries-programme/PeriPartum- even in patients with recovered LV function before SSP. Impor-
CardioMyopathy-PPCM-Registry), will provide more data on tantly, the risk for fatal outcome of SSP with regard to persisting
the benefit of medication during SSP.16 heart failure or death is particularly high if patients enter SSP with
We hypothesized that immediate treatment after delivery may LVEF that is not fully recovered. Moreover, African ethnicity may
have an influence on recovery after SSP. In line with this, our pre- further increase the risk of an adverse outcome of an SSP after
vious research suggested that a cleaved 16 kDa fragment of the PPCM. In case of SSP in a PPCM patient, management by an inter-
nursing hormone prolactin is a key player in the pathophysiology of disciplinary team of cardiologists, obstetricians, anaesthetists, and
PPCM and that blocking whole prolactin with BR can prevent onset neonatologists is recommended and all patients need to be moni-
of the disease in mice, and may prevent PPCM or promote healing tored carefully for at least 6 months postpartum, and perhaps for
from PPCM in humans.12,13 Indeed, we observed significantly better lifelong. In addition, despite some limitations such as small cohort

© 2017 The Authors

European Journal of Heart Failure © 2017 European Society of Cardiology
6 D. Hilfiker-Kleiner et al.

size and non-randomized design, our data suggest that progres- 7. Elkayam U, Tummala PP, Rao K, Akhter MW, Karaalp IS, Wani OR, Hameed A,

..............
sion of heart failure and fatal outcome of SSP may be attenuated
or prevented if a STHF + BR therapy is initiated immediately after
delivery in SSP. However, larger studies and, in particular, long-term
outcome data are urgently needed.
Acknowledgements
The authors thank S. Gutzke, B. Ritter, S. Thammen, M. Jungesblut,
and Sylvia Dennis for technical assistance, and Maggie Simpson for
data collection in Scotland.
Funding
This study was supported by the Deutsche Forschungsgesellschaft
(DFG, excellenc cluster Rebirth II), the Bundesministerium für Bil-
dung und Forschung (BMBF) and the Maurice Hatter Foundation.
A.H. was supported by the ‘Junge Akademie’ programme of Han-
nover Medical School.
Conflict of interest: none declared.
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Translational perspectives: a short clinical summary: An important component of the care for women with PPCM is counselling
regarding the risk of worsening heart failure or even death during or after a subsequent pregnancy (SSP). Our report on SSP
outcome in 34 PPCM patients in Germany, Scotland, and South Africa indicates that full recovery of left ventricular ejection fraction
(LVEF ≥50%) before SSP was associated with lower mortality and better cardiac function at follow-up. Addition of the prolactin
antagonist bromocriptine to standard heart failure therapy (beta-blockers and angiotensin-converting enzyme inhibitors/angiotensin
receptor blockers) immediately after delivery was safe and seemed to be associated with a better SSP outcome. Management by an
interdisciplinary team of cardiologists, obstetricians, anaesthetists, and neonatologists is recommended in all PPCM patients with a SSP,
including careful monitoring for at least 6 months postpartum.

© 2017 The Authors

European Journal of Heart Failure © 2017 European Society of Cardiology