USC study says risk of heart failure relapse need not deter some women from pregnancy

Contrary to popular belief, women who experience a rare form of heart failure during pregnancy may be able to have another child if they have recovered fully and are willing to take some risks with their own health.

That is the message of an article in the May 24th issue of the New England Journal of Medicine, authored by researchers from the Keck School of Medicine of the University of Southern California and the LAC+USC Medical Center.

"The desire to have children is very strong," says Uri Elkayam, M.D., professor of medicine, director of the Heart Failure Program at USC and the study's lead author. "A patient with heart disease is often advised by her physician to avoid pregnancy. I strongly believe that, as physicians, we are not supposed to make the decisions for the patients. Instead, we need to provide the patients with information and allow them and their families to make the decision."

The condition in question�called peripartum cardiomyopathy, or PPCM�is quite rare, occurring in just one out of 10,000 deliveries, explains Elkayam, who is considered one of the leading authorities on heart disease and pregnancy. "It presents, in most cases, in the last month of pregnancy or the first month after delivery, and definitely comes as a shock, because it appears in completely healthy young women," he says.

Women older than 30 years of age who carry more than one baby, are treated with tocolytic therapy to inhibit preterm contractions or have developed preeclampsia (high blood pressure in pregnancy) are at increased risk of developing PPCM.

Statistics show that approximately 20 percent of the women who develop this type of heart failure will continue to get worse, and either undergo heart transplantation or die. And yet, says Elkayam, more than half of the women with PPCM recover��and when they do, they want to get on with their lives. "We get calls and emails from doctors and women all over the country," says Elkayam, "and the most often-asked question is, 'Can I become pregnant again?'"

To answer that question, Elkayam and his USC colleagues conducted a survey of women with peripartum cardiomyopathy across the country. Not only did they look at the records of women who had survived the condition and became pregnant a second time, but they also interviewed those women or their physicians. In the end, they looked at a group of 44 women who had undergone a total of 60 pregnancies after the one that resulted in PPCM.

Of those 44 women, 28 had essentially fully recovered from their disease; the other 16 still had some amount of cardiac dysfunction when they became pregnant again. While there was evidence in both groups that pregnancy could result in a deterioration of cardiac function, it was in the 16 women who had started their pregnancies with some remaining dysfunction that the decision to become pregnant could be deadly. Indeed, three of them (19 percent) died after the subsequent pregnancy. Almost half of them had symptoms of heart failure during the pregnancy and a quarter of them experienced an even greater deterioration of their heart function. "In addition," notes Elkayam, "they had a high incidence of therapeutic abortions because of the fact that they became sick during the pregnancy. And those who delivered had a high incidence of premature babies."

In the women whose condition had normalized before pregnancy, the risks were much subtler�though still significant. "What we found was that even in this group, pregnancy was not event-free," says Elkayam. "About 21 percent of these women developed a more than 20 percent decrease in their heart function during pregnancy, and about half of these continued to have this decrease for months or years."

But there was good news for these women as well. "None of the patients in this group died," says Elkayam. "So although there is a risk of a worsening of heart function�and a risk that that worsening will occasionally be severe and persistent�the risk of death is very low."

Based on these findings, he adds, "our recommendations to patients with PPCM and persistent heart dysfunction are not to become pregnant again. The recommendations for women who recovered their heart function are somewhat more difficult. If the woman does not want to take any risk, then the advice is not to become pregnant. If there is a willingness to take some risk in order to have another child, then we feel that the risk is now much better defined."

"Conducting this study required a great deal of effort on our part," Elkayam says, "but we feel very good about the results and the fact that the information will allow women with PPCM around the world to make an educated decision about having more children."

Uri Elkayam, Padmini P. Tummala, Kalpana Rao, Mohammed W. Akhter, Ilyas S. Karaalp, Omari R. Wani, Afshan Hameed, Israel Gviazda, Avraham Shotan. "The Outcome of Subsequent Pregnancies in Women with Peripartum Cardiomyopathy." New England Journal of Medicine, May 24, 2001.