Becoming a mother despite pregnancy-related heart failure

Two new studies supported by the South African Medical Research Council (SAMRC) have been published by Cape Heart Institute Researcher Prof. Karen Sliwa and her team. These studies focus on treatment with bromocriptine and the possibility of subsequent pregnancy in women with Peripartum Cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is a but life-threatening disease that can affect 1: 1000 women with previously healthy hearts a few weeks before or after the birth of a child. Due to several factors the left ventricle's pumping capacity is severely reduced. 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, University of Cape Town. 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.  Professor Sliwa established the research field at Groote Schuur Hospital/University of Cape Town and has published fundamental scientific findings on PPCM disease. The research studies spanning from basic science including proteomic studies, to clinical and population studies received support from the SAMRC and the National Research Foundation.

In 2007, Professor Sliwa and her colleague from Germany, Professor Hilfiker-Kleiner, discovered that in the affected women, the breastfeeding hormone prolactin is broken down into a vascular-damaging degradation product that damages the heart vessels and, thus, causes heart failure. A ground-braking pilot study, led by Prof.  Sliwa published in the Journal Circulation 2010 indicated that blocking prolactin with the weaning drug bromocriptine promotes the healing of PPCM. Ten years later, a scientific study showed that administering bromocriptine for seven days in addition to heart failure therapy is sufficient. In addition to new treatment options, the researchers are looking into the question of how high the risk of heart failure recurring or progressing is in mothers who become pregnant again after PPCM.

Professor Sliwa and her collaborators has now published new studies on both topics in the globally leading cardiology journal "European Heart Journal". One study shows the good effectiveness of treatment with bromocriptine as a supplement to the usual therapy for heart failure, without increasing the risk of thrombosis. The second shows that even for women with mild ongoing heart failure, a subsequent pregnancy is possible with close cardiological care.

Bromocriptine improves heart health

PPCM affects one in 1000 pregnant women in South Africa. The life-threatening heart disease strikes those affected without warning and can lead to severe heart failure, and even death, within a short period of time. The symptoms are similar to complaints that occur more frequently towards the end of a pregnancy and shortly after childbirth – e.g. fatigue, shortness of breath, coughing, weight gain, particularly due to water retention in the lungs and legs, and heart palpitations. PPCM is therefore often not recognized and probably occurs more frequently than assumed. However, heart failure can be clearly detected with the help of a cardiac ultrasound and certain marker proteins in the blood. If treated in time, the heart often recovers completely, but heart failure can also remain.

Professor  Sliwa believes that bromocriptine is a promising treatment option for PPCM in addition to therapy with drugs commonly used for heart failure. A large global PPCM registry with more than PPCM patients confirmed its effectiveness and showed that bromocriptine clearly improves the heart health of mothers. Case reports of a higher risk of vascular blockages during treatment with the weaning medication were, however, not confirmed. These data not only confirm the effectiveness but also the safety of our treatment approach explains Prof Sliwa

Risk of subsequent pregnancy lower than expected

The second study looked at whether women with PPCM should generally be advised against becoming pregnant again. Participants were patients from the global PPCM registry of the European Society of Cardiology.  It has been shown in previous studies that patients with a still greatly reduced heart function who become pregnant again have a higher risk of a deterioration in the heart's pumping function in a subsequent pregnancy," says Professor Sliwa. However, in 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.

The data from our latest study indicate that current recommendations no longer strictly advise against subsequent pregnancies in PPCM patients, at least in women with mild heart failure," says Professor Sliwa. However, this relaxation can only be considered if the patient continues to be cared for by an experienced, interdisciplinary medical team and receives appropriate drug treatment. This is the case in our special outpatient clinic, where we have been caring for such women successfully for more than a decade year," emphasises Prof Sliwa.

Links:

The original paper on the effectiveness of bromocriptine “Bromocriptine treatment and outcomes in peripartum cardiomyopathy: the EORP PPCM registry” can be found here.

• Bromocriptine treatment and outcomes in peripartum cardiomyopathy: the EORP PPCM Registry (van der Meer et al,  European Heart Journal, 2024 (https://doi.org/10.1093/eurheartj/ehae559)

The original paper on the risks of a subsequent pregnancy after PPCM “Subsequent pregnancies in women with peripartum cardiomyopathy: prospective longitudinal data from the global ESC EORP PPCM Registry” can be found here.

• Pregnancies in women after peripartum cardiomyopathy: the Global the global European Society of Cardiology EuroObservational Research Programme Peri-Partum Cardiomyopathy Registry (Sliwa et al, European Heart Journal, 2025 https://doi.org/10.1093/eurheartj/ehaf006)