Peripartum cardiomyopathy occurs at

(D) Within 5 months[?]PPCM is a structural heart muscle disease that occurs in women either at the end of pregnancy or up to five months after giving birth.Peripartum Cardiomyopathy:Peripartum cardiomyopathy is a cardiomyopathy that occurs in the third trimester or in the months following delivery and presents with congestive heart failure.The etiology is poorly understood.Treatment must include anticoagulation because of the high risk of thromboembolism.Over one third of patients have complete recovery.A risk of recurrence exists in subsequent pregnancies.Peripartum Cardiomyopathy - Pathophysiology:Peripartum cardiomyopathy (PPCM) is a dilated cardiomyopathy documented with echocardiographic left ventricular dysfunction occurring in the last month of pregnancy or within 5 months of delivery.Patients with a prior history of myocardial disease are excluded from this definition.Risk factors include multi-parity, being black, older maternal age and preeclampsia. In a retrospective study of 123 women with PPCM, a history of hypertension was obtained in 43% of patients and twin pregnancies were reported in 13%.Idiopathic cardiomyopathy presenting with heart failure secondary to LV systolic dysfunction from 1 month antepartum, up to 5 months after delivery, when no other causes of heart failure is evident.Incidence of 1:300 to 1:4000 pregnancies.Predisposing factors:Multi-parity, Multiple Births, Smoking, diabetes, Pregnancy complicated by pre-eclampsia, eclampsia or hypertension, Advanced age or teenage pregnancy.Criteria for Peripartum Cardiomyopathy:Classic:Development of Cardiac failure in the last month of pregnancy or within 5 months after delivery.Absence of an identifiable cause for the cardiac failure.Absence of recognizable heart disease prior to the last month of pregnancy.Additional:Left ventricular systolic dysfunction demonstrated by classic Echo Cardio Graphic criteria such as depressed shortening fraction or ejection fraction.Peripartum Cardiomyopathy:Important diagnostic criteria are:Cardiac failure within last month of pregnancy or within 5 months postpartum.No determinable cause for failure.Absence of previous heart disease.Left ventricular dysfunction as evidenced on echocardiography-Ejection fraction <45%-Left ventricular end diastolic dimension >2.7cm/m2. Peripartum cardiomyopathy is a diagnosis of exclusion. The patients are usually multiparous & young (20-35 years). They complain of weakness, shortness of breath, cough, nocturnal dyspnoea & palpitation. Examination reveals - tachycardia, arrhythmia, peripheral oedema & pulmonary rales. Pregnancy is poorly tolerated in women with dilated cardiomyopathy.The treatment is bed rest, digitalis, diuretics (preload reduction), hydralazine or ACE inhibitors (postpartum) (after load reduction), beta blocker & anticoagulant therapy. Vaginal delivery is preferred. Epidural anaesthesia is ideal. There is no contraindication of breast feeding. Mortality is high (20-50%) due to pulmonary embolism & cerebral thrombosis. It may recur in subsequent pregnancies.Myocardial infarction is rare in pregnancy. Management is mostly as in on pregnant state. Coronary angioplasty, stenting and thrombolytic therapy has been done in pregnancy when indicated. Supine position and hypotension should be avoided. Labor: managed as with standard cardiac care. Elective delivery within two weeks of infarction should be avoided. Regional analgesia for pain in labor and p blockers for tachycardia may be used. Maternal pushing is avoided and second stage is shortened by forceps or vacuum. Syntocinon should be used in the third stage management as ergometrine may cause coronary artery spasm. Percutaneous transluminant coronary angioplasty can be done successfully around 36 weeks of pregnancy if needed.