---
title: Peripartum cardiomyopathy
description: What peripartum cardiomyopathy is, why it develops towards the end of pregnancy and after childbirth, how it is detected, which treatment approaches clinical guidelines describe and when urgent help is needed.
type: disease
preset: heart-failure
aliases:
  - PPCM
  - postpartum cardiomyopathy
sources:
  - tier: guideline
    org: esc
    title: 2025 ESC Guidelines for the management of cardiovascular disease and pregnancy
    year: 2025
    doi: 10.1093/eurheartj/ehaf193
    url: https://doi.org/10.1093/eurheartj/ehaf193
  - tier: guideline
    org: minzdrav-rf
    title: Дилатационная кардиомиопатия
    year: 2025
    url: https://cr.minzdrav.gov.ru/view-cr/1008_1
  - tier: guideline
    org: esc
    title: 2023 ESC Guidelines for the management of cardiomyopathies
    year: 2023
    doi: 10.1093/eurheartj/ehad194
    url: https://doi.org/10.1093/eurheartj/ehad194
  - tier: reference
    org: msd-manuals
    title: Heart Disease in Pregnancy (MSD Manual Professional Version)
    year: 2026
    url: https://www.msdmanuals.com/professional/gynecology-and-obstetrics/pregnancy-complicated-by-disease/heart-disease-in-pregnancy
  - tier: reference
    org: msd-manuals
    title: Heart Disease During Pregnancy (MSD Manual Consumer Version)
    year: 2025
    url: https://www.msdmanuals.com/home/women-s-health-issues/pregnancy-complicated-by-disease/heart-disease-during-pregnancy
sources_checked: 2026-10-13
review: null
---

Peripartum cardiomyopathy (PPCM) is a form of [dilated cardiomyopathy](../dilated-cardiomyopathy/) in which signs of [heart failure](../heart-failure/) appear towards the end of pregnancy or in the first months after childbirth.<Cite n={2} /> Sources define this time window differently. According to the Russian Ministry of Health guideline, it is the last month of pregnancy or the 5 months after delivery.<Cite n={2} /> The MSD Manual describes the period from the last month of pregnancy to 6 months after delivery.<Cite n={4} /> The European Society of Cardiology (ESC) refers to the peripartum period or the months following delivery, termination of pregnancy or miscarriage.<Cite n={1} /> The diagnosis is made only when no other cause of heart failure has been found.<Cite n={[1, 2]} />

<Diagram name="dilated-cardiomyopathy">
  <p slot="normal">
    Normally the left ventricle is of normal size and contracts with full strength. The ESC
    considers left ventricular function recovered after PPCM when the ejection fraction is above
    50%.<Cite n={1} />
  </p>
  <p slot="disease">
    In PPCM the left ventricle contracts weakly and may be enlarged.<Cite n={2} /> The ejection
    fraction is usually below 45%: this is how both the Russian Ministry of Health guideline and the ESC describe
    it.<Cite n={[1, 2]} />
  </p>
</Diagram>

## Why it happens

<Patient>

The exact cause often remains unknown; the disease is thought to have many contributing factors.<Cite n={[2, 5]} /> The risk is higher with multiple pregnancy (twins or more), repeated pregnancies, [pre-eclampsia](../hypertension-in-pregnancy/), smoking, poor nutrition, and long-term use of medicines that suppress contractions.<Cite n={[1, 2]} /> The mother's age also matters, but sources give different cut-offs: the Russian Ministry of Health guideline names adolescence or age over 30, the ESC under 20 or over 40, and the MSD Manual 30 or older.<Cite n={[1, 2, 4]} /> PPCM is more common and more severe in some ethnic groups and regions.<Cite n={[1, 2]} />

Some cases are linked to heredity: up to 20% of affected women carry changes in genes typical of DCM.<Cite n={2} /> That is why the guidelines advise considering genetic counselling and testing.<Cite n={[1, 2, 3]} />

</Patient>

<Student>

The Russian Ministry of Health guideline describes PPCM as a separate subsection of DCM; the ICD-10 code is O90.3 "Cardiomyopathy in the puerperium".<Cite n={2} /> The ESC lists the peripartum period among the non-genetic causes of DCM.<Cite n={3} /> Risk factors according to the ESC also include family history, pathogenic variants in DCM genes, previous PPCM, assisted reproductive technology, diabetes mellitus and hypertension.<Cite n={1} />

Proposed pathogenic mechanisms include systemic angiogenic imbalance, inflammation and oxidative stress: oxidative stress activates cathepsin D, which cleaves prolactin into a 16 kDa fragment; this fragment damages the endothelium and causes myocardial dysfunction.<Cite n={2} /> The ESC gives genetic counselling and testing in PPCM a class IIa recommendation.<Cite n={[1, 3]} />

</Student>

<HeartModel highlight={['left-ventricle']} />

## Symptoms

<Patient>

The symptoms are those of heart failure: breathlessness, palpitations and swollen feet.<Cite n={2} /> Similar sensations also occur in a normal pregnancy, so the disease may be recognised late.<Cite n={[2, 4]} /> The Russian Ministry of Health guideline advises suspecting PPCM in every woman whose condition is slow to return to normal after childbirth.<Cite n={2} />

The disease can begin suddenly: with acute heart failure, heart rhythm disturbances, including life-threatening ones, or cardiac arrest.<Cite n={2} /> In PPCM, blood clots form more often than in other forms of DCM; they can travel with the bloodstream to different organs, including the brain.<Cite n={2} />

</Patient>

<Student>

PPCM may present with acute HF, atrial fibrillation, ventricular arrhythmias, including fatal ones, and/or cardiac arrest.<Cite n={2} /> An LVEF below 35% increases the risk of LV thrombus; the rate of venous and arterial thromboembolism in the first 30 days after delivery was 6.8%.<Cite n={2} />

</Student>

## How it is diagnosed

<Patient>

When PPCM is suspected, the Russian Ministry of Health guideline advises examining the woman without delay so that treatment is not postponed.<Cite n={2} /> The tests include an [ECG](../../diagnostic/ecg/), a blood test for [natriuretic peptides](../../diagnostic/natriuretic-peptides/) and [echocardiography](../../diagnostic/echocardiography/), an ultrasound scan of the heart that shows how weak and how enlarged the <Structure id="left-ventricle">left ventricle</Structure> is and whether there is a blood clot in the heart.<Cite n={[1, 2]} /> The ESC also lists a physical examination, a chest X-ray and cardiac MRI.<Cite n={1} /> Echocardiography is repeated to check how well the treatment is working.<Cite n={2} />

</Patient>

<Student>

Diagnostic criteria for PPCM according to the Russian Ministry of Health guideline: HF during the last month of pregnancy or within 5 months after delivery, no other cause of HF, and LV systolic dysfunction (as a rule, LVEF below 45%).<Cite n={2} /> Measurement of BNP or NT-proBNP is recommended to diagnose HF and to monitor treatment.<Cite n={2} /> Echocardiography is repeated before discharge, at 6 weeks and 6 months after discharge, and then annually.<Cite n={2} /> Cardiac MRI is usually not needed to diagnose PPCM; contrast-enhanced MRI can be performed after delivery.<Cite n={2} />

</Student>

## How it is treated

<Patient>

PPCM is treated in the same way as [heart failure](../heart-failure/) with reduced left ventricular function, but with pregnancy and breastfeeding taken into account.<Cite n={[2, 5]} /> Treatment is led by a team of doctors: cardiologists, obstetrician-gynaecologists and neonatologists.<Cite n={[1, 2]} /> Some classes of heart failure medicines may be unsafe for the unborn baby and the newborn.<Cite n={2} /> The ESC does not recommend ACE inhibitors, angiotensin receptor blockers (ARBs), angiotensin receptor–neprilysin inhibitors (ARNIs), mineralocorticoid receptor antagonists (MRAs), SGLT2 inhibitors and some other medicines during pregnancy.<Cite n={1} /> After delivery, the ESC recommends optimising guideline-directed heart failure treatment, taking into account which medicines are contraindicated during breastfeeding.<Cite n={1} /> Which medicines are suitable is decided by the doctor.

The Russian Ministry of Health guideline and the ESC allow adding a medicine that suppresses production of the hormone prolactin; it stops breast milk production, and the Russian Ministry of Health guideline advises giving medicines against blood clots together with it.<Cite n={[1, 2]} /> In severe heart failure, the ESC and the Russian Ministry of Health guideline allow for not breastfeeding, because milk production places high demands on the body.<Cite n={[1, 2]} />

</Patient>

<Student>

PPCM is treated in the same way as HF with LV systolic dysfunction; antiarrhythmic and anticoagulant therapy and mechanical circulatory support may be added.<Cite n={2} /> A drug that blocks prolactin secretion may be considered in addition to optimal HF treatment to enhance recovery of LV function (ESC IIb B); adding at least prophylactic low-molecular-weight heparin to it should be considered (ESC IIa C).<Cite n={1} /> Anticoagulants are recommended in the presence of intracardiac thrombus, signs of systemic embolism, atrial fibrillation or atrial flutter.<Cite n={2} />

In cardiogenic shock, the ESC recommends urgent delivery by caesarean section as soon as the foetus is viable, and advises considering early transfer to a centre with mechanical circulatory support.<Cite n={1} /> If drug therapy fails, mechanical circulatory support or heart transplantation may be recommended.<Cite n={2} /> According to the Russian Ministry of Health guideline, early implantation of a cardioverter-defibrillator should not be discussed in newly diagnosed PPCM, because LV function recovers rapidly on standard HF therapy; implantation may be considered if ventricular function has not normalised after pregnancy.<Cite n={2} /> With an LVEF below 35%, the ESC allows a wearable cardioverter-defibrillator.<Cite n={1} /> After complete LV recovery, the ESC proposes continuing HF treatment for at least 12 months when a reversible course of HF is assumed.<Cite n={1} />

</Student>

## Outlook and the next pregnancy

<Patient>

In many women heart function recovers, most often within the first 6 months; according to the ESC, in 25–60%.<Cite n={[1, 2]} /> PPCM can come back in a later pregnancy, especially if the heart has not fully recovered.<Cite n={4} /> That is why the ESC and the Russian Ministry of Health guideline advise counselling for all women after PPCM about the risk of recurrence and about contraception, even if heart function has recovered.<Cite n={[1, 2]} />

</Patient>

<Student>

A poor prognosis is associated with an LVEF below 30%, an LV end-diastolic diameter of 6.0 cm or more, and RV involvement.<Cite n={2} /> According to the Russian Ministry of Health guideline, the risk of recurrence in subsequent pregnancies is 30–50%.<Cite n={2} /> In the mWHO 2.0 classification, previous PPCM with more than mild residual LV impairment is class IV: an extremely high risk of maternal mortality or severe morbidity.<Cite n={1} />

</Student>

## When to call an ambulance

PPCM can present with acute heart failure, dangerous heart rhythm disturbances, cardiac arrest and thromboembolism.<Cite n={2} /> The Russian Ministry of Health guideline advises calling an ambulance immediately for prolonged chest pain, severe and lasting breathlessness, fainting, or swelling of one leg with redness and pain.<Cite n={2} /> Call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK).

If there are signs of a stroke (sudden weakness in an arm or leg, usually on one side of the body, difficulty speaking, sudden problems with vision or balance), call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK) straight away.<Cite n={2} /> If breathlessness is getting worse, wakes you at night, you can only sleep sitting up, or you have frequent palpitations, tell your doctor as soon as possible.<Cite n={2} />

<Quiz />