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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Peripartum cardiomyopathy

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Resting breathlessness, hypoxia, orthopnoea, pulmonary oedema, syncope, hypotension or persistent tachycardia late in pregnancy or postpartum requires same-day emergency assessment; do not attribute it to normal pregnancy without examination and cardiac testing.

Synopsis

Distinguish pathological peripartum heart failure from normal pregnancy symptoms and coordinate pregnancy-safe acute, chronic and future-pregnancy care.

  • PPCM is otherwise-unexplained heart failure from LV systolic dysfunction, usually LVEF below 45%, towards the end of pregnancy or in the months after birth.
  • Orthopnoea, PND, resting tachycardia, raised JVP, hypoxia and pulmonary oedema are not normal pregnancy discomforts.
  • TTE confirms ventricular dysfunction and identifies RV involvement, valve regurgitation and intracardiac thrombus.
  • Always exclude pre-eclampsia-related pulmonary oedema, PE, ACS/SCAD, myocarditis, sepsis and previously unrecognised cardiomyopathy or valve disease.
  • Treatment during pregnancy differs from postpartum HFrEF: ACE inhibitors, ARBs, ARNIs, MRAs and SGLT2 inhibitors are avoided during pregnancy.
  • Severe dysfunction and the postpartum state increase thromboembolic risk; anticoagulation is individualised by LVEF, thrombus, AF and bromocriptine use.
  • Recovery may take months and does not abolish relapse risk; continue follow-up and counsel before any later pregnancy.
  • Bromocriptine is not routine lactation suppression and has important MHRA hypertension/cardiovascular contraindications; any PPCM use is specialist and off-label.

Key red flags

Acute danger

Pulmonary oedema, hypoperfusion, malignant arrhythmia, embolic neurology or severe biventricular failure requires critical care and Pregnancy Heart Team activation.

Alternative emergency

Pleuritic pain, haemoptysis or disproportionate hypoxia suggests PE; chest pain/ECG change requires ACS and SCAD assessment.

Investigation priorities

01
12-lead ECG and continuous monitoring when unwellFirst step

Detect arrhythmia, conduction disease and ACS clues.

Management branches

AcuteSuspected PPCM

Peripartum HF symptoms with objective abnormality.

  1. Assess ABCDE, oxygen only for hypoxaemia, ECG/monitoring, IV access, labs including NT-proBNP/troponin and urgent echo; involve obstetrics and cardiology immediately.
  2. Treat pulmonary congestion with cautious loop diuretic and position/ventilatory support; manage unstable arrhythmia by standard emergency principles with fetal considerations.
  3. Actively test for PE, ACS/SCAD, pre-eclampsia, sepsis, valve disease and alternative cardiomyopathy according to findings.
  4. If shock or severe biventricular failure, transfer early to a centre with Pregnancy Heart Team, mechanical support, advanced HF and neonatal capability.
PostpartumOptimise after birth

Haemodynamically stable postpartum PPCM.

  1. Transition to NICE HFrEF disease-modifying therapy, checking lactation compatibility and infant factors medicine-by-medicine; enalapril is the preferred ACE inhibitor during breastfeeding of a full-term healthy infant.
  2. Continue careful diuresis, rhythm surveillance and anticoagulation when indicated; image for LV thrombus when severe apical dysfunction is present.
  3. Consider bromocriptine only in a specialist PPCM protocol after explicit MHRA

Key medicines

FurosemideCommon oral starting dose 20-40 mg once daily; in acute pulmonary oedema use an individualised IV dose based on severity and prior exposure.Use the minimum effective dose: hypovolaemia, electrolyte loss and renal injury can reduce maternal and placental perfusion. Monitor weight, BP, U&E and fetal context.
Enalapril (postpartum only)After delivery, start 2.5 mg orally once daily for symptomatic heart failure under close BP supervision; titrate over 2-4 weeks toward the usual maintenance 20 mg/day in one or two doses, to a maximum 40 mg/day in two divided doses, as tolerated.Contraindicated during pregnancy. Check BP, renal function and potassium before and after initiation/titration; review hypovolaemia, renal-artery stenosis, hyperkalaemia and previous ACE-inhibitor angioedema. During breastfeeding monitor the infant for poor feeding, lethargy, pallor, inadequate weight gain and, especially when young, reduced wet nappies.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • 2025 ESC Guidelines for cardiovascular disease during pregnancyCurrent PPCM definition, Pregnancy Heart Team and pregnancy-specific treatment.
  • 2023 ESC Guidelines for the management of cardiomyopathiesPhenotype, recovery and family context.
  • NICE NG106: Chronic heart failure in adultsPostpartum HFrEF framework.
  • NHS SPS: Using ACE inhibitors during breastfeedingEnalapril preference and infant scope.
  • MHRA: Bromocriptine postpartum blood-pressure warningOctober 2024 UK contraindications and non-routine status.
  • Enalapril 10 mg tablets SmPCExact adult heart-failure initiation, titration, maximum dose and monitoring safeguards.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
contraindication
, BP and thrombosis review—not as routine lactation suppression.
  • Arrange early HF follow-up and repeat echo; escalate persistent severe dysfunction for wearable/implantable defibrillator or advanced-HF assessment at the appropriate interval.