Women with peripartum cardiomyopathy (PPCM) had lower than expected rates of morbidity and mortality with a subsequent pregnancy (SSP), according to a prospective registry study published Feb. 12 in the European Heart Journal.

Karen Sliwa, MD, PhD, FACC, et al., assessed maternal and neonatal outcomes of patients with PPCM experiencing an SSP, who were included in the ESC EuroObservational Research Programme PPCM Registry after a first diagnosis of PPCM. The global registry includes 752 women with PPCM from 51 countries included from 2012 to 2023.

The present study included 332 patients enrolled at 11 sites across Europe, the Middle East, Asia-Pacific and Africa. Their mean age at SSP onset was 30 years, and 36% were of African ethnicity and 27% Caucasian. At their initial PPCM diagnosis, their LVEF was 32±10%.

Results showed that of the 98 SSPs, among 73 women, 25 (26%) ended prematurely due to therapeutic termination (20/25), miscarriage (4/25), and stillbirth (1/25). Overall, there were 74 neonates.

Looking at LVEF, 26% of patients had a persistent reduction to <50% before the SSP, and it was <40% in only 6%. Furthermore, regardless of baseline LVEF at SSP, patient characteristics were similar. At follow-up (median 198 days), the mean LVEF was 50%. And it was ≥50% in 69% of SSPs. Compared with women with an SSP baseline LVEF <50%, fewer women with LVEF ≥50% were on HF pharmacotherapies before the SSP and they experienced a significant decline in LVEF.

Clinical worsening, a composite of all-cause death, cardiovascular hospitalization or decline in LVEF by ≥10% and to <50%, was observed in 20% of patients. The rate of all-cause mortality was 2%. Signs/symptoms of heart failure (HF) and worsening of NYHA class occurred in 26% and 22% of SSPs, respectively.

The authors note that outcomes were similar in women from Africa and from other regions.

Looking at pregnancy outcomes, 24% of deliveries were pre-term, 20% of babies were low birth weight and all-cause neonatal mortality was 3%.

The authors state the findings suggest that in many women with PPCM and improved LVEF, an SSP could be considered under careful pre- and postpartum observation and with appropriate medical therapy. Also, reclassification of an SSP with persisting mild LV impairment from modified World Health Organization (mWHO) Class IV (contraindicated) to mWHO III could be considered, when continuous surveillance is ensured by an experienced medical team and with appropriate pharmacological management.

In an accompanying editorial comment, Olayinka J. Agboola, MD, MPH, and Garima Sharma, MBBS, FACC, describe how to best counsel PPCM patients who hope to become pregnant again, noting that "a careful and methodological approach could improve outcomes." They write that the findings should be "implemented in a case-by-case risk assessment using LVEF as the primary prognosticator," along with precision medicine tools, genetic evaluation, biomarkers, echocardiography and functional status as "additional risk stratification in assessment alongside shared decision-making."