الفهرس 
physiology of the cardiovascular system and changes during pregnancyOnly 14 pages are availabe for public view
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Abstract
Peripartum cardiomyopathy (PPCM) is a rare and life- threatening disease that affects young women in the last month of pregnancy or within 5 months of delivery. The incidence rate in the world is estimated to be 1:3000 to 1:4000. Symptoms of PPCM vary greatly and may be obscured by common physiological aspects of pregnancy. Therefore, the incidence rate might be higher. PPCM is defined by the following four criteria:
1. Development of cardiac failure in the last month of pregnancy or within 5 months of delivery;
2. Absence of an identifiable cause of cardiac failure;
3. Absence of recognisable heart disease prior to the last month of pregnancy;
4. Left ventricular systolic dysfunction demonstrated by echocardiographic criteria, such as left ventricular ejection fraction < 45% .
It is thought to be more prevalent in multiparous women, pregnancies with multiple foetuses, women of African descent and in women receiving longterm tocolytic therapy (with β-adrenergic agonists). Other possible risk factors include toxaemia of pregnancy, maternal cocaine abuse and nutritional deficiencies.The etiology of this disease remains uncertain but number of possible causes of (PPCM) including myocarditis , abnormal immune response to pregnancy , viral infection , there have been a few reports of familial (PPCM) .
Common symptoms include fatigue, palpitations, nocturia, orthopnea and pedal edema. However, the classical symptoms of heart failure can be masked especially in obese women . Peripartum cardiomyopathy presents in I.C.U. with acute onset of heart failure .The presentation with reduced cardiac output , tissue hypoperfusion , increase in the pulmonary capillary and tissue congestion is often life threatening and requires urgent treatment .The diagnosis of PPCM is based on symptoms and clinical findings in combination with appropriate investigations, such as electrocardiography , chest radiograph , biomarkers , echocardiography and cardiac MRI (used in prognosis more evident than in diagnosis) .
Treatment in ICU is directed toward symptomatic relief , improvement of cardiac function and oxygenation that may help to prevent end organ dysfunction and multiple organ failure .The use of continuous positive air way pressure (CPAP) and noninvasive positive pressure ventilation (NIPPV) in acute cardiogenic pulmonary edema associated with significant reduction in the need for tracheal intubation and mechanical ventilation. Administration of diuretics is indicated in presence of symptoms of fluid retention ,inotropic agents used in presence of peripheral hypo- perfusion with or without congestion or pulmonary edema refractory to diuretics and vasodilators. In addition to conventional therapy new lines include milrinone (phospho-diesterase III inhibitor), Levosimendan (calcium sensitizer ) , bromocriptine , and pentoxifyllin (inhibitor of TNF production ) . Temporary mechanical circulatory assistance indicated in patients not responding to conventional therapy. This include an intra aortic balloon pump and a left ventricular assist device.
There are several possible outcomes in PPCM. Some women remain stable for long periods, while others get worse slowly. Others get worse very quickly and may be candidates for a heart transplant. The death rate may be as high as 25 - 50%. The prognosis is poor in patients with persistent cardiomyopathy. Subsequent pregnancies are often associated with recurrence of left ventricular systolic dysfunction, subsequent pregnancy may lead to a significant and persistent depression of LVEF to CHF and even death.