It’s a rare form of congestive heart failure (inefficient blood pumping), and its exact causes remain unclear. (1) This rare disorder can develop during the last month of pregnancy when a pregnant woman’s heart becomes enlarged and weakened. If it begins during pregnancy, it’s considered PPCM (peripartum cardiomyopathy). (2)(3) The numbers vary, but studies estimate that PPCM occurs in one out of every 3,000 live births in the US. (2) The morbidity incidence could be higher, but the condition might have been misdiagnosed or overlooked because it has similar symptoms to the third trimester (such as swelling) and other heart conditions (such as irregular heartbeat). (2)(3) For example, the prevalence of postpartum cardiomyopathy with postpartum preeclampsia is estimated to be around 30-45%. Their symptoms may be similar, leading to diagnostic difficulties. (3) Sadly, a 2017 Heart & Lung study showed that after a diagnosis of PPCM, a new mom might also experience mental health challenges, including postpartum depression. (4) Although it’s rare, PPCM is an obstetric emergency that doctors and new moms should watch for because it can lead to heart failure, possibly even death. (5)

What Happens In Postpartum Cardiomyopathy

This type of dilated cardiomyopathy happens because the left ventricle (the heart’s main pumping chamber) dilates and stretches. (2) The dilated ventricle causes systolic dysfunction (pumping problems). As the muscles weaken, the heart chambers are enlarged and pump less blood to supply your body’s needs. This can affect important organs like the liver, lungs, and other body systems. These factors distinguish it from other heart conditions: (2)

No recognized heart disease before pregnancy Left ventricular systolic dysfunction Symptoms of heart failure within the last month of pregnancy or five months of delivery

Postpartum cardiomyopathy is the most common form of PPCM. Around 71-98% of moms who experience cardiomyopathy show symptoms during the postpartum period instead of pregnancy. (3) It’s rare in prepartum (before giving birth), and 90% of the cases occur within the first two months of childbirth. (5) It can happen even with a normal pregnancy.

How Serious Is Postpartum Cardiomyopathy?

It’s a serious condition. Studies show that only 50% of new moms may be expected to fully recover heart function. Although others survive even with reduced heart function, the estimated mortality rate in the US is around 6-8%. (2)(6)

Is Postpartum Cardiomyopathy Permanent?

Recovery rates vary and can depend on the extent of heart muscle damage. This can be measured using the LVEF (normal left ventricular ejection fraction): (6)

Normal LVEF ranges from 0.55 to 0.70. Patients with cardiomyopathy are those with less than 0.45 LVEF. Recovery is defined as an improvement by more than 0.20 or LVEF over 0.50.

A 2006 study showed that 62% of the patients with a mean initial LVEF of 0.20 improved to over 0.50 in a follow-up after 43 months. However, 10% required a transplant. (6)(7) Those who recovered had a baseline LVEF of over 0.30. Around 75% of these patients showed a big improvement (>0.45 LVEF) two months after diagnosis. This study recorded no deaths despite the low LVEF (<0.20) in some patients. (7)

How Long Does Postpartum Cardiomyopathy Last?

Studies show that recovery from postpartum cardiomyopathy usually happens around 2-6 months postpartum but can also last as long as 48 months. (6)

How Long Can You Live With Cardiomyopathy?

Life expectancy after a diagnosis of PPCM depends on several factors, including your baseline LVEF as explained above. But with treatment, patients can survive for many years. Harvard-affiliated Brigham and Women’s Hospital heart failure specialist Dr. Lynne Warner Stevenson said: (8)

Signs & Symptoms

Symptoms of postpartum cardiomyopathy can include: (9)

Palpitations (feeling of your heart racing or skipping beats) Cardiac arrhythmias (irregular heartbeat) Fatigue or exhaustion Nocturia (increased nighttime urination) Shortness of breath with activity (when lying flat) Swollen neck veins Swollen ankles, legs, or hands (can also be a sign of postpartum swelling) Low blood pressure or a quick drop when you stand up Unexplained weight gain Abdominal discomfort or stomach pain

The clinical presentation or signs of PPCM: (2)

Dyspnea (difficult or labored breathing) Tachycardia (fast heart rate of over 100 beats a minute) Edema (swelling) Multiple blood clots Acute hypoxia (drop in blood oxygen levels)

However, these signs can also be present in other heart conditions or unrelated medical conditions such as pneumonia and postpartum depression. (2)

When To Call A Medical Professional

Postpartum cardiomyopathy can lead to heart failure. So, it’s important to call your healthcare team if you experience any of the above-mentioned signs and symptoms. Warning signs can include: (2)(9)

Palpitations Chest pain Fainting Any new or unexplained symptom Exhaustion Coughing up blood

Causes

The exact cause of postpartum cardiomyopathy remains unknown, but researchers believe these factors might contribute: (2)(9)(10)

Genetics Vascular dysfunction (problems in some parts of the heart, such as left ventricular dysfunction) Inflamed heart muscles Hypertensive disorders (e.g., postpartum preeclampsia) Viral myocarditis (heart inflammation due to a virus such as the Epstein-Barr virus, parvovirus B19, and human herpesvirus 6) (11) Autoimmunity (in this autoimmune response, the immune system mistakenly attacks heart cells called cardiomyocytes after a period of immunosuppression during pregnancy) Nutritional deficiencies (e.g., selenium deficiency) Hemodynamic stresses (problems with blood flow) Pregnancy can strain your heart muscles Hormone imbalance (low levels of progesterone and estrogen, hormones that can help prevent hypertension) High prolactin levels, a hormone necessary to stimulate breastmilk production

Risk Factors

Some of the reported risk factors: (2)(12)(13)

Postpartum cardiomyopathy in a previous pregnancy African-American ethnicity Advanced maternal age Pregnancy-induced hypertension or preeclampsia Three or more previous pregnancies Multiple gestations (pregnant with two or more babies) Obesity Chronic hypertension Prolonged use of tocolytics (anti-contraction medications to suppress premature labor) Diabetes mellitus (high blood sugar) Autoimmune diseases (e.g., lupus) Cocaine abuse Breastfeeding (due to prolactin release) (14)

Breastfeeding With Postpartum Cardiomyopathy

Prolactin (the hormone that helps you produce milk) is believed to be among the causes of this condition (one treatment option is to block this hormone). Studies show that breastfeeding can still be encouraged for mild cases but the mom’s treatment should be prioritized. However, moms with severely impaired systolic function are advised against breastfeeding. (15)(16)

Future Pregnancies

There’s a high risk (>20%) of relapse in subsequent pregnancies, so women are usually advised against a new pregnancy, especially if their heart hasn’t regained its full work capacity (>0.55 LVEF). (3) Another pregnancy can cause additional heart damage, with increased risks of heart failure.

Can You Minimize The Risk? Prevention & Lifestyle Changes

Some ways to help you cope and manage the condition:

Weight monitoring Low fat and low salt diet Avoid smoking and alcohol Doctor-approved exercise

Treatment

A multidisciplinary healthcare team (including your obstetrician, a cardiologist, and a pediatrician) helps determine the best treatment plan. Medications can include: (2)(14)

Diuretics (helps your body eliminate sodium and water to reduce blood pressure) Beta-blockers (cause the heart rate to slow down to reduce blood pressure) Anticoagulants (for anticoagulation, prevents clotting) ACE inhibitors (angiotensin-converting enzyme inhibitors) Bromocriptine (blocks prolactin release from the pituitary gland) Treatment of underlying medical conditions or viral infections

Surgical procedures can include: (2)(14)

ICD (implantable cardioverter-defibrillator) – a device that detects and controls rapid heartbeat CRT (cardiac resynchronization therapy) – pacemaker restores normal heartbeat pattern Ventricle-assist device – helps pump blood

A heart transplant might be necessary in extreme cases, or severe congestive heart failure persists.

Complications & Long-Term Effects

Postpartum cardiomyopathy can lead to the following conditions: (3)(13)

Cardiac arrhythmias (irregular heartbeat; can be deadly) Persistent cardiac dysfunction Congestive heart failure (inefficient blood pumping) Thromboembolic events (blood clots in the heart that can travel to other parts of the body, possibly leading to stroke) Progression to severe heart failure (might require a heart transplant) Death

Diagnosis

Some ways to diagnose PPCM: (2)(3)(6)

Physical exam – checks for signs of fluid in the lungs and abnormal heart sounds ECG (electrocardiogram) – checks for electrical signals from your heart Echocardiogram – an echocardiography procedure (uses sound) to check for heart function MRI (magnetic resonance imaging) – helps with pathophysiology (changes that accompany the condition) and prognosis (forecast of the likely outcome) Chest X-ray – checks for heart enlargement Chest CT scan (computerized tomography) – creates detailed images of your heart, including the status of your blood vessels Coronary angiography – checks for there are problems with blood flow (such as restrictions going to the heart) Cardiac protein assays (made by the liver and released to the bloodstream in response to an infection) Standard blood tests – to check for signs of anemia, evidence of infection, levels of certain markers in the blood (such as sodium and potassium), and kidney, liver, or thyroid function Endomyocardial biopsy (a minimally invasive procedure done in extreme circumstances)

Your doctor may also perform a differential diagnosis to rule out other conditions with similar signs and symptoms: (2)(6)

Accelerated hypertension Postpartum preeclampsia Eclampsia (severe preeclampsia with seizures) Diastolic dysfunction (both ventricles have pumping problems) Systemic infection (a disease, such as flu, affecting the entire body) Pulmonary embolism (a blood clot in the lungs) Amniotic fluid embolism (part of the fluid that surrounds your baby in the uterus enters your bloodstream)

REFERENCES (1) https://pdfs.semanticscholar.org/4c69/9a65ecaec583bf45f0767355c5ed2c8555b4.pdf?_ga=2.56305195.1047495375.1648377988-1291395407.1646035449 (2) https://www.hindawi.com/journals/jp/2010/149127/ (3) https://www.researchgate.net/publication/319426941_Peripartum_Cardiomyopathy_A_Systematic_Literature_Review (4) https://www.heartandlung.org/article/S0147-9563(17)30014-6/fulltext (5) Shaikh N. (2010). An obstetric emergency called peripartum cardiomyopathy!. Journal of emergencies, trauma, and shock, 3(1), 39–42. https://doi.org/10.4103/0974-2700.58664 (6) Bhattacharyya, A., Basra, S. S., Sen, P., & Kar, B. (2012). Peripartum cardiomyopathy: a review. Texas Heart Institute Journal, 39(1), 8–16. (7) https://www.researchgate.net/publication/6865574_Improved_outcomes_in_peripartum_cardiomyopathy_with_contemporary (8) https://www.health.harvard.edu/press_releases/heart-failure-treatments-can-extend-life (9) Bauersachs J, König T, van der Meer P, Petrie MC, Hilfiker-Kleiner D, Mbakwem A, Hamdan R, Jackson AM, Forsyth P, de Boer RA, Mueller C, Lyon AR, Lund LH, Piepoli MF, Heymans S, Chioncel O, Anker SD, Ponikowski P, Seferovic PM, Johnson MR, Mebazaa A, Sliwa K. Pathophysiology, diagnosis and management of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy. Eur J Heart Fail. 2019 Jul;21(7):827-843. doi: 10.1002/ejhf.1493. Epub 2019 Jun 27. PMID: 31243866. (10) https://www.researchgate.net/publication/23189547_Aetiology_and_risk_factors_of_peripartum_cardiomyopathy_A_systematic_review (11) Bültmann BD, Klingel K, Näbauer M, Wallwiener D, Kandolf R. High prevalence of viral genomes and inflammation in peripartum cardiomyopathy. Am J Obstet Gynecol. 2005 Aug;193(2):363-5. doi: 10.1016/j.ajog.2005.01.022. PMID: 16098856. (12) https://www.researchgate.net/publication/262927316_Temporal_Trends_in_Incidence_and_Outcomes_of_Peripartum_Cardiomyopathy_in_the_United_States_A_Nationwide_Population-Based_Study (13) Abboud J, Murad Y, Chen-Scarabelli C, Saravolatz L, Scarabelli TM. Peripartum cardiomyopathy: a comprehensive review. Int J Cardiol. 2007 Jun 12;118(3):295-303. doi: 10.1016/j.ijcard.2006.08.005. Epub 2007 Jan 17. PMID: 17208320. (14) Hilfiker-Kleiner D, Kaminski K, Podewski E, Bonda T, Schaefer A, Sliwa K, Forster O, Quint A, Landmesser U, Doerries C, Luchtefeld M, Poli V, Schneider MD, Balligand JL, Desjardins F, Ansari A, Struman I, Nguyen NQ, Zschemisch NH, Klein G, Heusch G, Schulz R, Hilfiker A, Drexler H. A cathepsin D-cleaved 16 kDa form of prolactin mediates postpartum cardiomyopathy. Cell. 2007 Feb 9;128(3):589-600. doi: 10.1016/j.cell.2006.12.036. PMID: 17289576. (15) https://www.researchgate.net/publication/333987105_To_Breastfeed_or_Not_to_Breastfeed_With_Peripartum_Cardiomyopathy (16) https://www.cfrjournal.com/articles/postpartum-cardiomyopathy-and-considerations-breastfeeding

title: “Postpartum Cardiomyopathy Symptoms Treatment Should You Worry About It Motherhood Community” ShowToc: true date: “2022-12-02” author: “Mark Weber”

It’s a rare form of congestive heart failure (inefficient blood pumping), and its exact causes remain unclear. (1) This rare disorder can develop during the last month of pregnancy when a pregnant woman’s heart becomes enlarged and weakened. If it begins during pregnancy, it’s considered PPCM (peripartum cardiomyopathy). (2)(3) The numbers vary, but studies estimate that PPCM occurs in one out of every 3,000 live births in the US. (2) The morbidity incidence could be higher, but the condition might have been misdiagnosed or overlooked because it has similar symptoms to the third trimester (such as swelling) and other heart conditions (such as irregular heartbeat). (2)(3) For example, the prevalence of postpartum cardiomyopathy with postpartum preeclampsia is estimated to be around 30-45%. Their symptoms may be similar, leading to diagnostic difficulties. (3) Sadly, a 2017 Heart & Lung study showed that after a diagnosis of PPCM, a new mom might also experience mental health challenges, including postpartum depression. (4) Although it’s rare, PPCM is an obstetric emergency that doctors and new moms should watch for because it can lead to heart failure, possibly even death. (5)

What Happens In Postpartum Cardiomyopathy

This type of dilated cardiomyopathy happens because the left ventricle (the heart’s main pumping chamber) dilates and stretches. (2) The dilated ventricle causes systolic dysfunction (pumping problems). As the muscles weaken, the heart chambers are enlarged and pump less blood to supply your body’s needs. This can affect important organs like the liver, lungs, and other body systems. These factors distinguish it from other heart conditions: (2)

No recognized heart disease before pregnancy Left ventricular systolic dysfunction Symptoms of heart failure within the last month of pregnancy or five months of delivery

Postpartum cardiomyopathy is the most common form of PPCM. Around 71-98% of moms who experience cardiomyopathy show symptoms during the postpartum period instead of pregnancy. (3) It’s rare in prepartum (before giving birth), and 90% of the cases occur within the first two months of childbirth. (5) It can happen even with a normal pregnancy.

How Serious Is Postpartum Cardiomyopathy?

It’s a serious condition. Studies show that only 50% of new moms may be expected to fully recover heart function. Although others survive even with reduced heart function, the estimated mortality rate in the US is around 6-8%. (2)(6)

Is Postpartum Cardiomyopathy Permanent?

Recovery rates vary and can depend on the extent of heart muscle damage. This can be measured using the LVEF (normal left ventricular ejection fraction): (6)

Normal LVEF ranges from 0.55 to 0.70. Patients with cardiomyopathy are those with less than 0.45 LVEF. Recovery is defined as an improvement by more than 0.20 or LVEF over 0.50.

A 2006 study showed that 62% of the patients with a mean initial LVEF of 0.20 improved to over 0.50 in a follow-up after 43 months. However, 10% required a transplant. (6)(7) Those who recovered had a baseline LVEF of over 0.30. Around 75% of these patients showed a big improvement (>0.45 LVEF) two months after diagnosis. This study recorded no deaths despite the low LVEF (<0.20) in some patients. (7)

How Long Does Postpartum Cardiomyopathy Last?

Studies show that recovery from postpartum cardiomyopathy usually happens around 2-6 months postpartum but can also last as long as 48 months. (6)

How Long Can You Live With Cardiomyopathy?

Life expectancy after a diagnosis of PPCM depends on several factors, including your baseline LVEF as explained above. But with treatment, patients can survive for many years. Harvard-affiliated Brigham and Women’s Hospital heart failure specialist Dr. Lynne Warner Stevenson said: (8)

Signs & Symptoms

Symptoms of postpartum cardiomyopathy can include: (9)

Palpitations (feeling of your heart racing or skipping beats) Cardiac arrhythmias (irregular heartbeat) Fatigue or exhaustion Nocturia (increased nighttime urination) Shortness of breath with activity (when lying flat) Swollen neck veins Swollen ankles, legs, or hands (can also be a sign of postpartum swelling) Low blood pressure or a quick drop when you stand up Unexplained weight gain Abdominal discomfort or stomach pain

The clinical presentation or signs of PPCM: (2)

Dyspnea (difficult or labored breathing) Tachycardia (fast heart rate of over 100 beats a minute) Edema (swelling) Multiple blood clots Acute hypoxia (drop in blood oxygen levels)

However, these signs can also be present in other heart conditions or unrelated medical conditions such as pneumonia and postpartum depression. (2)

When To Call A Medical Professional

Postpartum cardiomyopathy can lead to heart failure. So, it’s important to call your healthcare team if you experience any of the above-mentioned signs and symptoms. Warning signs can include: (2)(9)

Palpitations Chest pain Fainting Any new or unexplained symptom Exhaustion Coughing up blood

Causes

The exact cause of postpartum cardiomyopathy remains unknown, but researchers believe these factors might contribute: (2)(9)(10)

Genetics Vascular dysfunction (problems in some parts of the heart, such as left ventricular dysfunction) Inflamed heart muscles Hypertensive disorders (e.g., postpartum preeclampsia) Viral myocarditis (heart inflammation due to a virus such as the Epstein-Barr virus, parvovirus B19, and human herpesvirus 6) (11) Autoimmunity (in this autoimmune response, the immune system mistakenly attacks heart cells called cardiomyocytes after a period of immunosuppression during pregnancy) Nutritional deficiencies (e.g., selenium deficiency) Hemodynamic stresses (problems with blood flow) Pregnancy can strain your heart muscles Hormone imbalance (low levels of progesterone and estrogen, hormones that can help prevent hypertension) High prolactin levels, a hormone necessary to stimulate breastmilk production

Risk Factors

Some of the reported risk factors: (2)(12)(13)

Postpartum cardiomyopathy in a previous pregnancy African-American ethnicity Advanced maternal age Pregnancy-induced hypertension or preeclampsia Three or more previous pregnancies Multiple gestations (pregnant with two or more babies) Obesity Chronic hypertension Prolonged use of tocolytics (anti-contraction medications to suppress premature labor) Diabetes mellitus (high blood sugar) Autoimmune diseases (e.g., lupus) Cocaine abuse Breastfeeding (due to prolactin release) (14)

Breastfeeding With Postpartum Cardiomyopathy

Prolactin (the hormone that helps you produce milk) is believed to be among the causes of this condition (one treatment option is to block this hormone). Studies show that breastfeeding can still be encouraged for mild cases but the mom’s treatment should be prioritized. However, moms with severely impaired systolic function are advised against breastfeeding. (15)(16)

Future Pregnancies

There’s a high risk (>20%) of relapse in subsequent pregnancies, so women are usually advised against a new pregnancy, especially if their heart hasn’t regained its full work capacity (>0.55 LVEF). (3) Another pregnancy can cause additional heart damage, with increased risks of heart failure.

Can You Minimize The Risk? Prevention & Lifestyle Changes

Some ways to help you cope and manage the condition:

Weight monitoring Low fat and low salt diet Avoid smoking and alcohol Doctor-approved exercise

Treatment

A multidisciplinary healthcare team (including your obstetrician, a cardiologist, and a pediatrician) helps determine the best treatment plan. Medications can include: (2)(14)

Diuretics (helps your body eliminate sodium and water to reduce blood pressure) Beta-blockers (cause the heart rate to slow down to reduce blood pressure) Anticoagulants (for anticoagulation, prevents clotting) ACE inhibitors (angiotensin-converting enzyme inhibitors) Bromocriptine (blocks prolactin release from the pituitary gland) Treatment of underlying medical conditions or viral infections

Surgical procedures can include: (2)(14)

ICD (implantable cardioverter-defibrillator) – a device that detects and controls rapid heartbeat CRT (cardiac resynchronization therapy) – pacemaker restores normal heartbeat pattern Ventricle-assist device – helps pump blood

A heart transplant might be necessary in extreme cases, or severe congestive heart failure persists.

Complications & Long-Term Effects

Postpartum cardiomyopathy can lead to the following conditions: (3)(13)

Cardiac arrhythmias (irregular heartbeat; can be deadly) Persistent cardiac dysfunction Congestive heart failure (inefficient blood pumping) Thromboembolic events (blood clots in the heart that can travel to other parts of the body, possibly leading to stroke) Progression to severe heart failure (might require a heart transplant) Death

Diagnosis

Some ways to diagnose PPCM: (2)(3)(6)

Physical exam – checks for signs of fluid in the lungs and abnormal heart sounds ECG (electrocardiogram) – checks for electrical signals from your heart Echocardiogram – an echocardiography procedure (uses sound) to check for heart function MRI (magnetic resonance imaging) – helps with pathophysiology (changes that accompany the condition) and prognosis (forecast of the likely outcome) Chest X-ray – checks for heart enlargement Chest CT scan (computerized tomography) – creates detailed images of your heart, including the status of your blood vessels Coronary angiography – checks for there are problems with blood flow (such as restrictions going to the heart) Cardiac protein assays (made by the liver and released to the bloodstream in response to an infection) Standard blood tests – to check for signs of anemia, evidence of infection, levels of certain markers in the blood (such as sodium and potassium), and kidney, liver, or thyroid function Endomyocardial biopsy (a minimally invasive procedure done in extreme circumstances)

Your doctor may also perform a differential diagnosis to rule out other conditions with similar signs and symptoms: (2)(6)

Accelerated hypertension Postpartum preeclampsia Eclampsia (severe preeclampsia with seizures) Diastolic dysfunction (both ventricles have pumping problems) Systemic infection (a disease, such as flu, affecting the entire body) Pulmonary embolism (a blood clot in the lungs) Amniotic fluid embolism (part of the fluid that surrounds your baby in the uterus enters your bloodstream)

REFERENCES (1) https://pdfs.semanticscholar.org/4c69/9a65ecaec583bf45f0767355c5ed2c8555b4.pdf?_ga=2.56305195.1047495375.1648377988-1291395407.1646035449 (2) https://www.hindawi.com/journals/jp/2010/149127/ (3) https://www.researchgate.net/publication/319426941_Peripartum_Cardiomyopathy_A_Systematic_Literature_Review (4) https://www.heartandlung.org/article/S0147-9563(17)30014-6/fulltext (5) Shaikh N. (2010). An obstetric emergency called peripartum cardiomyopathy!. Journal of emergencies, trauma, and shock, 3(1), 39–42. https://doi.org/10.4103/0974-2700.58664 (6) Bhattacharyya, A., Basra, S. S., Sen, P., & Kar, B. (2012). Peripartum cardiomyopathy: a review. Texas Heart Institute Journal, 39(1), 8–16. (7) https://www.researchgate.net/publication/6865574_Improved_outcomes_in_peripartum_cardiomyopathy_with_contemporary (8) https://www.health.harvard.edu/press_releases/heart-failure-treatments-can-extend-life (9) Bauersachs J, König T, van der Meer P, Petrie MC, Hilfiker-Kleiner D, Mbakwem A, Hamdan R, Jackson AM, Forsyth P, de Boer RA, Mueller C, Lyon AR, Lund LH, Piepoli MF, Heymans S, Chioncel O, Anker SD, Ponikowski P, Seferovic PM, Johnson MR, Mebazaa A, Sliwa K. Pathophysiology, diagnosis and management of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy. Eur J Heart Fail. 2019 Jul;21(7):827-843. doi: 10.1002/ejhf.1493. Epub 2019 Jun 27. PMID: 31243866. (10) https://www.researchgate.net/publication/23189547_Aetiology_and_risk_factors_of_peripartum_cardiomyopathy_A_systematic_review (11) Bültmann BD, Klingel K, Näbauer M, Wallwiener D, Kandolf R. High prevalence of viral genomes and inflammation in peripartum cardiomyopathy. Am J Obstet Gynecol. 2005 Aug;193(2):363-5. doi: 10.1016/j.ajog.2005.01.022. PMID: 16098856. (12) https://www.researchgate.net/publication/262927316_Temporal_Trends_in_Incidence_and_Outcomes_of_Peripartum_Cardiomyopathy_in_the_United_States_A_Nationwide_Population-Based_Study (13) Abboud J, Murad Y, Chen-Scarabelli C, Saravolatz L, Scarabelli TM. Peripartum cardiomyopathy: a comprehensive review. Int J Cardiol. 2007 Jun 12;118(3):295-303. doi: 10.1016/j.ijcard.2006.08.005. Epub 2007 Jan 17. PMID: 17208320. (14) Hilfiker-Kleiner D, Kaminski K, Podewski E, Bonda T, Schaefer A, Sliwa K, Forster O, Quint A, Landmesser U, Doerries C, Luchtefeld M, Poli V, Schneider MD, Balligand JL, Desjardins F, Ansari A, Struman I, Nguyen NQ, Zschemisch NH, Klein G, Heusch G, Schulz R, Hilfiker A, Drexler H. A cathepsin D-cleaved 16 kDa form of prolactin mediates postpartum cardiomyopathy. Cell. 2007 Feb 9;128(3):589-600. doi: 10.1016/j.cell.2006.12.036. PMID: 17289576. (15) https://www.researchgate.net/publication/333987105_To_Breastfeed_or_Not_to_Breastfeed_With_Peripartum_Cardiomyopathy (16) https://www.cfrjournal.com/articles/postpartum-cardiomyopathy-and-considerations-breastfeeding