Childbirth is usually considered a moment of happiness and beginnings, but for numerous women worldwide, it could become a life-or-death situation. Though excessive bleeding, infection, and hypertensive complications are well-known reasons for maternal mortality, an underemphasized yet life-threatening condition—peripartum cardiomyopathy (PPCM)—is slowly emerging as a silent killer. This unusual but dangerous manifestation of heart failure occurs in women late in pregnancy or shortly after delivery, frequently with symptoms that are indistinguishable from usual pregnancy discomforts.According to the most recent UN global estimates, 303,000 women annually lose their lives as a result of complications in pregnancy or childbirth—an average of 830 women per day, or approximately one every two minutes. Most of these deaths could be averted with proper and timely medical attention. But extremes of inequality exist: two-thirds of maternal deaths happen in sub-Saharan Africa, with India and Nigeria alone contributing one-third of the world total.Although the number of deaths worldwide has decreased by 44% since 1990, from 532,000 to 303,000, the achievement has not been commensurate with the size of global commitments over decades to cut down these figures. Most of the deaths remain underreported, especially in areas with weak healthcare systems and inadequate data collection mechanisms.What Is Peripartum Cardiomyopathy?Peripartum cardiomyopathy is a form of heart failure that occurs in the final month of pregnancy or within five months after delivery. It compromises the function of the heart muscle, making it less efficient at circulating blood throughout the body. Clinically, it appears as heart failure with low ejection fraction (EF Although PPCM is uncommon—affecting between 1 in 1,000 and 1 in 4,000 pregnancies in the United States—it's a significant health risk when it does occur. It has been found to be more common in the southern parts of the U.S., but worldwide estimates are uncertain due to under-reporting and under-diagnosis.One of the most perilous features of PPCM is how readily it can be confused with normal pregnancy symptoms. Fatigue, shortness of breath, swelling in the feet and ankles, and mild chest pain are all normal pregnancy occurrences. But for women with PPCM, these symptoms can indicate a heart in distress. Severer forms cause difficulty in lying down due to breathing (orthopnea), night-time breathing distress (paroxysmal nocturnal dyspnea), palpitations of the heart, and even decreased blood pressure or cardiogenic shock."The PPCM clinical syndrome is easily likely to be mistaken for late-gestational complains," states Consultant – Gynecology Dr. Madhu Bindhu. "It usually brings delays in diagnosis, which, being critical at times, causes anxiety. Earlier recognition, notably via echocardiographic screening, is responsible for better outcome improvement."How Is PPCM Diagnosed and Treated?Diagnosis often starts with a 12-lead ECG and a chest X-ray, but the definitive test is a 2D echocardiogram, which can verify left ventricular dysfunction. In complicated cases, a cardiac MRI may be performed to exclude other structural or inflammatory causes of heart failure.Treatment is with a typical heart failure regimen, adjusted for pregnancy or postpartum status. This can be diuretics to decrease fluid accumulation, beta-blockers to manage heart rate, and ACE inhibitors, utilized postpartum. Anticoagulants can be given to avoid blood clots, a frequent complication in PPCM.A treatment that is under investigation and shows promise is Bromocriptine, a prolactin inhibitor with disease-modifying effects. In severely ill patients, more advanced treatments like ECMO (extracorporeal membrane oxygenation), intra-aortic balloon pumps, or LVADs (left ventricular assist devices) are options.Pregnancy, Delivery, and the Cardiomyopathy EquationFor pregnant women diagnosed with PPCM, delivery plans need to be tailored. Vaginal delivery is favored for hemodynamically stable patients, states Dr. Bindhu. But those with critical cardiac decompensation are advised to have cesarean sections at any gestational age.Significantly, a multidisciplinary approach by cardiologists, obstetricians, and intensive care specialists is vital. Pregnancy heart teams dedicated to caring for complex PPCM cases can make a life-changing difference and lower mortality risks.Outcome in PPCM is variable. Many women recover if treated appropriately, but some might have chronic heart failure or potentially life-threatening complications. Poor prognostic indicators are an ejection fraction less than 30%, dilatation of the left ventricle, biventricular dysfunction, prolongation of the QT interval, and non-Caucasian ethnicity.Public education, early diagnosis, and enhanced access to prenatal care are the pillars of preventing maternal mortality due to PPCM. In resource-poor countries, enhancing diagnostic capacity and educating clinicians to diagnose PPCM is crucial.Peripartum cardiomyopathy is still one of the least talked-about but most perilous maternal medical conditions in the world. As we continue to aim to decrease maternal death rates, particularly in low-resource environments, it is important that PPCM be part of the discussion. Every pregnant woman should have the means and attention that can identify and treat the condition in time—so motherhood can start in hope, not heartbreak.Dr Madhu Bindhu is a Consultant – Gynecology at Manipal Hospital, Vijayawada in India
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