Hope for women with heart disease in the peripartum period

Peripartum cardiomyopathy (PPCM) is a life-threatening heart disease in which a pregnant or postpartum woman’s heart becomes weakened and enlarged. It can strike without warning, usually in the last month of pregnancy or in the months after the baby is born. In South Africa, one in 1000 pregnant women are affected, which is higher than the global average. Professor Karen Sliwa, director of the Cape Heart Institute and a senior cardiologist in the Division of Cardiology, Department of Medicine, and her team, have been making major strides in the treatment and understanding of PPCM.

“While PPCM can vary in terms of severity, mortality rates can be as high as 20%, meaning one in five women succumb to this condition,” said Professor Sliwa. “This despite the young age of the patients.

The risk factors of PPCM are complex and multifactorial. Genetics plays a large role and so too does maternal age, with very young mothers and mothers of advanced maternal age at a higher risk. While the causes of PPCM are still poorly understood, work by Professor Sliwa and her team at the Cape Heart Institute have shown that it relates to the production of prolactin, a breastfeeding hormone. Pregnant women will begin producing prolactin early in pregnancy, with levels rising during the pregnancy to prepare the body for lactation. Women who develop PPCM produce an abnormal form of prolactin which leads to a narrowing of the blood vessels and can ultimately damage the heart.

The Cape Heart Institute is Africa’s leading centre for research on cardiac disease in pregnancy, including PPCM. A multi-professional team from the fields of cardiology, obstetrics, anaesthesia and neonatology care for those women at Groote Schuur Hospital. The disease is not only treated at the clinic but is also one of its research focuses with one of the world's largest PPCM registries with data and biomaterials from more than 700 patients.

Risk in future pregnancies lower than expected 

A recent study by Sliwa and her team, published in the European Heart Journal, the leading journal of cardiology globally, found that the risk for mothers who had experienced PPCM in earlier pregnancies was lower than expected for future pregnancies.

“This latest finding contradicts earlier studies which found that patients with a still greatly reduced heart function who become pregnant again have a higher risk of further deterioration of the heart’s function in a subsequent pregnancy,” said Sliwa. “However, our current studies have found that the risk of the mothers becoming seriously ill or even dying was lower than expected. Even in women who continued to suffer from mild heart failure after giving birth, the condition of the heart did not worsen after another pregnancy.”

This is because of a change in management of PPCM over the past decade. Care now includes a multidisciplinary team (obstetrician, anaesthetists, cardiologists) and the use of adequate doses of specific heart failure medication while pregnant and after giving birth.

“This is an important breakthrough for women with PPCM as it means the recommendations to strictly advise against future pregnancies can be relaxed.”

“This is an important breakthrough for women with PPCM as it means the recommendations to strictly advise against future pregnancies can be relaxed,” said Sliwa. “So long as the mother is cared for by an experienced, interdisciplinary medical team and receives appropriate drug treatment.”

An effective and safe treatment for PPCM

Sliwa and her team have also long been investigating the efficacy of bromocriptine, a drug used to manage conditions of high prolactin, a breastfeeding hormone.  A pilot-study led by Sliwa & colleagues at Chris Hani Baragwanath Hospital in Soweto, published 2010, showed promising results for treatment with bromocriptine. This was followed by a larger global study conducted by Sliwa and colleagues which included more than 500 patients and was published in the European Heart Journal in September 2024. This recent study showed that treatment with a disease-specific therapy, which includes bromocriptine, along with other drugs commonly used for heart failure, resulted in better maternal outcomes and a marked reduction in mortality for patients after six months compared to women who were treated only with the heart failure drugs.

“While PPCM remains a serious disease, the reduction in mortality rates and permanent damage to the heart is greatly reduced as a result of our increased understanding of the condition.”

“While PPCM remains a serious disease, the reduction in mortality rates and permanent damage to the heart is greatly reduced as a result of our increased understanding of the condition,” said Sliwa. “Because of this, a future pregnancy can now still be considered for many women.”