Study Background and Disease Burden
Peri-partum cardiomyopathy (PPCM) is a rare but serious cardiac condition that manifests towards the end of pregnancy or in the months following delivery. It is characterized by left ventricular systolic dysfunction leading to heart failure. Women diagnosed with PPCM face a challenging prognosis in subsequent pregnancies (SSPs), as the risk of heart failure progression or maternal mortality remains a significant concern. Historically, clinical guidance has often been cautious or even contraindicated regarding SSPs in women recovering from PPCM, especially with persistent left ventricular impairment. However, existing data are limited, often retrospective, and not representative of diverse ethnic or sociodemographic groups. This gaps in knowledge constrains evidence-based counseling and management strategies for affected women desiring future pregnancies.
Study Design
The study analyzed prospective data collected through a sub-study of the global European Society of Cardiology (ESC) PPCM Registry between 2012 and 2023. It included 332 women diagnosed with PPCM, with a focused cohort of 73 women who experienced a total of 98 subsequent pregnancies. Maternal outcomes were assessed in terms of clinical worsening—defined by a composite endpoint of all-cause mortality, cardiovascular rehospitalization, or decline of left ventricular ejection fraction (LVEF) by ≥10 percentage points to below 50%. Neonatal outcomes included pre-term birth, low birth weight, and neonatal mortality rates.
Key Findings
Among the 98 SSPs, 26% ended prematurely, most commonly due to therapeutic termination (20/25), with fewer cases of miscarriage (4/25) and stillbirth (1/25). At baseline, 26% of women had an LVEF <50%, with only 6% exhibiting severe impairment (LVEF <40%). Clinical deterioration occurred in 20% of SSPs, including a 2% all-cause maternal mortality rate. Signs and symptoms of heart failure were present in 26% of pregnancies, with 22% experiencing worsening New York Heart Association (NYHA) functional class.
Importantly, the mean LVEF at follow-up was 50%, with 69% of SSPs demonstrating preserved ventricular function (LVEF ≥50%). No significant differences in outcomes were observed between African women and other ethnic groups, suggesting broad applicability of findings. Adverse neonatal outcomes were notable: 24% of births were pre-term, 20% of neonates were low birth weight, and neonatal mortality stood at 3%.
An unexpected result was that women with baseline LVEF ≥50% were less frequently receiving heart failure pharmacotherapy during pregnancy and postpartum than those with LVEF <50%. Paradoxically, the LVEF declined significantly in this latter group, highlighting the role of guideline-directed medical therapy continuation in mitigating cardiac function deterioration.
Expert Commentary
These findings upend previous conceptions that reduced ventricular function before SSP definitively portends worse outcomes. The lower-than-anticipated maternal morbidity and mortality may reflect advances in multidisciplinary care and heart failure management during pregnancy. The observation that women with preserved LVEF yet reduced heart failure therapy experienced LVEF decline underscores the critical importance of pharmacological treatment continuity despite pregnancy challenges.
The study’s implications are profound for guidelines: it challenges the absolute contraindication (mWHO class IV) status currently assigned to SSPs with mild persistent ventricular dysfunction and supports reconsidering such pregnancies as mWHO class III, provided they are managed under expert care with appropriate medication regimens.
Limitations include inherent registry-based design constraints and relatively short post-partum follow-up (median 198 days), warranting further long-term studies. Nonetheless, the diverse multiethnic European cohort strengthens the generalizability of results.
Conclusion
The ESC EuroObservational Research Programme provides the most comprehensive contemporary data on pregnancy outcomes following PPCM, demonstrating overall favorable maternal and neonatal outcomes with careful management. Baseline left ventricular dysfunction (<50% LVEF) alone should not preclude pregnancy, given the absence of increased adverse outcomes and no further LVEF decline in this group. Meanwhile, ensuring continuation of heart failure pharmacotherapy in women with preserved ventricular function appears vital. Therapeutic pregnancy termination remains an important consideration in select cases, occurring in roughly a fifth of SSPs reported.
These findings support refining risk stratification frameworks for patients with PPCM contemplating further pregnancies and underscore the need for multidisciplinary care teams with expertise in cardio-obstetrics to optimize outcomes.
References
1. Sliwa K, Jackson A, Viljoen C, et al. Pregnancies in women after peri-partum cardiomyopathy: the global European Society of Cardiology EuroObservational Research Programme Peri-Partum Cardiomyopathy Registry. Eur Heart J. 2025;46(11):1031-1040. doi:10.1093/eurheartj/ehaf006
2. Hilfiker-Kleiner D, Haghikia A, Nonhoff J, Bauersachs J. Peripartum cardiomyopathy: current management and future perspectives. Eur Heart J. 2015;36(18):1090-1097. doi:10.1093/eurheartj/ehu030
3. Elkayam U. Clinical practice. Peripartum cardiomyopathy. N Engl J Med. 2006;355(8): 928-934. doi:10.1056/NEJMcp054320
