Correspondence
Postpartum Cardiomyopathy – A Cardiac Emergency for Gynecologists, General Practitioners, Internists, Pulmonologists, and Cardiologists: Case Numbers Are Tiny
Dtsch Arztebl Int 2009; 106(11): 190. DOI: 10.3238/arztebl.2009.0190
Even after reading the lead article extremely I can only conclude that a possible positive effect of bromocriptine on the course of this condition is not even probable. It is a fact that the pregnancy and breastfeeding periods are characterized by weakened immunity. Stress factors such as birth, sleep deprivation, exhaustion, and unfavorable socioeconomic conditions can aggravate this situation. These factors in combination provide enough reason for acquiring a viral infection after the birth, which may take a fulminant course and develop, for example, into myocarditis. It is obvious that treatment should then adhere to the guidelines of the German Society of Cardiology. A conclusion is reached before the proof has been found. The cited studies have tiny case numbers. Before drawing conclusions—as in the South Africa study—from the allegedly successful treatment of 6 (!) patients, a thorough medical history of these women should be taken. How much time passed after the birth, which NYHA category were they in before the birth, etc.Even if the groups were comparable, the case numbers are still too small to draw statistical conclusions.
None of the studies documented whether the women were breast feeding, and if they did, for how long. Was weaning done by using medication such as bromocriptine or cabergoline? Of the 6 patients from Germany in whom "bromocriptine as an attempt to cure" was used, all had notably improved pump function 6 months later, but a control cohort was lacking. In the article's introduction, the authors reported that 80% made a good recovery anyway. I was amused by the investigations of serum concentrations of oxidized low density lipoprotein as an indicator for oxidative stress and activity of the prolactin cleaving enzyme cathepsin D. PPCM patients had a strongly raised titer compared with healthy, breastfeeding mothers. It would be interesting to know whether the mothers with cardiac failure were actually fully breast feeding. Maybe a high concentration of prolactin as an indicator for successful breast feeding has a protective function? As long as no clear scientific proof has been provided for the recommendation to consider prolonged treatment with bromocriptine, I would advise the utmost caution in disrupting the unity of mother and baby by disrupting their breastfeeding bond. Abrupt cessation of breast feeding might even result in a deterioration of the pathology owing to psychological stress.
DOI: 10.3238/arztebl.2009.0190
Dr. med. Swana Swalve-Bordeaux
Bahnhofsstr. 11
24340 Eckernförde, Germany
swalve-bordeaux@gmx.de
1.
Hilfiker-Kleiner D, Schieffer E, Meyer GP, Podewski E, Drexler H: Postpartum cardiomyopathie: a cardiac emergency for gynecologists, general practitioners, internists, pulmonologists and cardiologists. [Die postpartale Kardiomyopathie. Ein kardiologischer Notfall für Gynäkologen, Hausärzte, Internisten, Pneumologen und Kardiologen]. Dtsch Arztebl Int 2008; 105(44): 751–6.
