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Obstetric Medicine: The Medicine of Pregnancy Response to Adam Morton's Letter 'Reply to: Timothy A C Snow, Cara A Wasywich and Fiona M
Stewart. A case of breathlessness during pregnancy: the difficulty in diagnosing heart failure'
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Obstetric Medicine: The Medicine of Pregnancy
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Response to Adam Morton’s Letter ‘Reply severity of the left ventricular impairment that she had a pre-existing cardiomyopathy. At the time of presentation anti- phospholipid syndrome or phaeochromocytoma were not considered. Neither condition has developed subsequently.
difficulty in diagnosing heart failure’ Placental abruption is likely to explain the disseminated intra-vascular coagulopathy and ischaemic complications observedin this case.
Dr Morton asks about the role for aldosterone antagonists Our thanks to Dr Morton for his thought provoking letter.
for women with dilated cardiomyopathies in pregnancy.
He asks whether the clomipramine may have contributed Unfortunately in this situation the diagnosis was made at to her dilated cardiomyopathy. Our patient had been on clomi- the time of cardiac arrest and fetal death. Spironolactone is a pramine for several years prior to her admission. If she had Class C drug in pregnancy mainly because of reports of femin- prior left ventricular impairment from clomipramine we ization of male rats but also as a diuretic it will reduce placental would have expected her cardiac function to have decompen- perfusion and therefore may reduce fetal growth. There may be sated earlier in pregnancy (around 20 –28 weeks’ gestation, cor- a role for the use of this drug in women with refractory heart responding to the time of maximal rate of increase in cardiac failure in pregnancy in an attempt to prolong the duration of output). She presented at 31 weeks’ gestation with at most the pregnancy, to improve fetal outcome. Ideally use of this a two-week history of deteriorating shortness of breath. This medication should be carefully monitored and reported to a patient was re-challenged with clomipramine a year ago due central registry such as the European Working Group on to escalating obsessive compulsive disorder. Over that time Peripartum Cardiomyopathy to advance our understanding we have seen continued improvement of her left ventricular of the risks and benefits of aldosterone antagonists in The diagnosis of a peripartum cardiomyopathy was a diagnosis made in the absence of any other identifiablecause despite the relatively early onset of symptoms at about Fiona M Stewart *† and Cara A Wasywich † 29 weeks’ gestation. The European Society of Cardiology *Greenlane Cardiovascular Service, Auckland City Hospital; Working Group on Peripartum Cadiomyopathy has extended †National Womens Health, Auckland City Hospital, New Zealand their definition of peripartum cardiomyopathy earlier than Correspondence to: Fiona M Stewart. Email: the final four weeks of a pregnancy to encompass the small number of women who present earlier without any otherapparent cause for the cardiomyopathy.1 A cardiac biopsy was performed with no diagnostic histopathology. It wasnegative for iron and amyloid stains. Coronary angiography 1 Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of was normal. Viral studies were negative although these knowledge on aetiology, diagnosis, management, and therapyof peripartum cardiomyopathy: a position statement for the Heart do not rule out a postviral cardiomyopathy and there was Failure Association of the European Society of Cardiology Working no family history of a dilated cardiomyopathy. It was highly Group on peripartum cardiomyopathy. Eur J Heart Fail 2010; unlikely given the gestation at the onset of symptoms and the

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