Download PDF
Am J Perinatol 2021; 38(12): 1289-1296
DOI: 10.1055/s-0040-1712451
Original Article

Pre-pregnancy Obesity and the Risk of Peripartum Cardiomyopathy

Seo-Ho Cho
1   Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California
,
Stephanie A. Leonard
2   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
,
Audrey Lyndon
3   Rory Meyers College of Nursing, New York University, New York, New York
,
Elliott K. Main
4   California Maternal Quality Care Collaborative, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
,
Barbara Abrams
5   Division of Epidemiology, University of California Berkeley School of Public Health, Berkeley, California
,
Afshan B. Hameed
6   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California Irvine School of Medicine, Irvine, California
7   Division of Cardiology, Department of Medicine, University of California Irvine School of Medicine, Irvine, California
,
Suzan L. Carmichael
8   Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
9   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
› Author Affiliations Funding This project was supported by grant R01NR017020 from the National Institute of Nursing Research (awarded to S.L.C.), postdoctoral fellowship F32HD091945 from the Eunice Kennedy Shriver National Institute of Child Health and Development ( awarded to S.A.L.), and Stanford Maternal and Child Health Research Institute. The funding sources had no involvement in the conduct of research or preparation of this article.
› Further Information
    Permissions and Reprints

Abstract

Objective The aim of this study is to evaluate the contribution of pre-pregnancy obesity and overweight to peripartum cardiomyopathy.

Study Design This population-based study used linked birth record and maternal hospital discharge data from live births in California during 2007 to 2012 (n = 2,548,380). All women who had a diagnosis of peripartum cardiomyopathy during the childbirth hospitalization or who were diagnosed with peripartum cardiomyopathy during a postpartum hospital readmission within 5 months of birth were identified as cases. Pre-pregnancy body mass index (BMI, kg/m2) was classified as normal weight (18.5–24.9), overweight (25.0–29.9), obesity class 1 (30.0–34.9), obesity class 2 (35.0–39.9), and obesity class 3 (≥40). Because of small numbers, we excluded women with underweight BMI, and in some analyses, we combined obesity classes into one group. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) expressing associations between BMI and peripartum cardiomyopathy, adjusted for maternal age, race/ethnicity, education, health care payer, parity, plurality, and comorbidities.

Results The overall prevalence of peripartum cardiomyopathy during hospital admissions was 1.3 per 10,000 live births (n = 320). Unadjusted ORs were 1.32 (95% CI: 1.01–1.74) for women with overweight BMI and 2.03 (95% CI: 1.57–2.62) for women with obesity, compared with women with normal pre-pregnancy BMI. Adjusted ORs were 1.26 (95% CI: 0.95–1.66) for overweight women and 1.38 (95% CI: 1.04–1.84) for women with obesity. The ORs suggested a dose–response relationship with increasing levels of obesity, but the 95% CIs for the specific classes of obesity included 1.00.

Conclusion Pre-pregnancy obesity was associated with an increased risk of peripartum cardiomyopathy. These findings underscore the importance of BMI during pregnancy. There is a need to recognize the increased risk of peripartum cardiomyopathy in women with high BMI, especially in the late postpartum period.

Key Points

  • Pre-pregnancy obesity affects maternal health.

  • Effects may extend to peripartum cardiomyopathy.

  • The risk includes peripartum cardiomyopathy that emerges postpartum.

Keywords

body mass index - heart failure - hypertensive disorder - maternal health - pregnancy complication

Supplementary Material



Publication History

Received: 14 November 2019

Accepted: 15 April 2020

Article published online:
08 June 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.

 

  • References

  • 1 Elkayam U, Akhter MW, Singh H. et al. Pregnancy-associated cardiomyopathy: clinical characteristics and a comparison between early and late presentation. Circulation 2005; 111 (16) 2050-2055
    CrossrefPubMedGoogle Scholar
  • 2 Masoomi R, Shah Z, Arany Z, Gupta K. Peripartum cardiomyopathy: an epidemiologic study of early and late presentations. Pregnancy Hypertens 2018; 13: 273-278
    CrossrefPubMedGoogle Scholar
  • 3 Sliwa K, Petrie MC, Hilfiker-Kleiner D. et al. Long-term prognosis, subsequent pregnancy, contraception and overall management of peripartum cardiomyopathy: practical guidance paper from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy. Eur J Heart Fail 2018; 20 (06) 951-962
    CrossrefPubMedGoogle Scholar
  • 4 Nelson-Piercy C, Head C. Management of cardiomyopathies in pregnancy. In: Gatzoulis MA, Steer PJ. eds. Heart Disease and Pregnancy. 2 ed. Cambridge: Cambridge University Press; 2016: 160-173
    Google Scholar
  • 5 Kolte D, Khera S, Aronow WS. et al. Temporal trends in incidence and outcomes of peripartum cardiomyopathy in the United States: a nationwide population-based study. J Am Heart Assoc 2014; 3 (03) e001056
    CrossrefPubMedGoogle Scholar
  • 6 Harper MA, Meyer RE, Berg CJ. Peripartum cardiomyopathy: population-based birth prevalence and 7-year mortality. Obstet Gynecol 2012; 120 (05) 1013-1019
    CrossrefPubMedGoogle Scholar
  • 7 Gunderson EP, Croen LA, Chiang V, Yoshida CK, Walton D, Go AS. Epidemiology of peripartum cardiomyopathy: incidence, predictors, and outcomes. Obstet Gynecol 2011; 118 (03) 583-591
    CrossrefPubMedGoogle Scholar
  • 8 Hameed AB, Lawton ES, McCain CL. et al. Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy. Am J Obstet Gynecol 2015; 213 (03) 379.e1-379.e10
    CrossrefPubMedGoogle Scholar
  • 9 Sliwa K, Hilfiker-Kleiner D, Petrie MC. et al; Heart Failure Association of the European Society of Cardiology Working Group on Peripartum Cardiomyopathy. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010; 12 (08) 767-778
    CrossrefPubMedGoogle Scholar
  • 10 Elkayam U. Clinical characteristics of peripartum cardiomyopathy in the United States: diagnosis, prognosis, and management. J Am Coll Cardiol 2011; 58 (07) 659-670
    CrossrefPubMedGoogle Scholar
  • 11 Petersen EE, Davis NL, Goodman D. et al. Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR Morb Mortal Wkly Rep 2019; 68 (18) 423-429
    CrossrefPubMedGoogle Scholar
  • 12 Brown CS, Bertolet BD. Peripartum cardiomyopathy: a comprehensive review. Am J Obstet Gynecol 1998; 178 (02) 409-414
    CrossrefPubMedGoogle Scholar
  • 13 Sliwa K, Fett J, Elkayam U. Peripartum cardiomyopathy. Lancet 2006; 368 (9536): 687-693
    CrossrefPubMedGoogle Scholar
  • 14 Bello N, Rendon ISH, Arany Z. The relationship between pre-eclampsia and peripartum cardiomyopathy: a systematic review and meta-analysis. J Am Coll Cardiol 2013; 62 (18) 1715-1723
    CrossrefPubMedGoogle Scholar
  • 15 Parikh P, Blauwet L. Peripartum cardiomyopathy and preeclampsia: overlapping diseases of pregnancy. Curr Hypertens Rep 2018; 20 (08) 69
    CrossrefPubMedGoogle Scholar
  • 16 Behrens I, Basit S, Lykke JA. et al. Hypertensive disorders of pregnancy and peripartum cardiomyopathy: a nationwide cohort study. PLoS One 2019; 14 (02) e0211857
    CrossrefPubMedGoogle Scholar
  • 17 Louis JM, Mogos MF, Salemi JL, Redline S, Salihu HM. Obstructive sleep apnea and severe maternal-infant morbidity/mortality in the United States, 1998-2009. Sleep (Basel) 2014; 37 (05) 843-849
    CrossrefPubMedGoogle Scholar
  • 18 Shani H, Kuperstein R, Berlin A, Arad M, Goldenberg I, Simchen MJ. Peripartum cardiomyopathy – risk factors, characteristics and long-term follow-up. J Perinat Med 2015; 43 (01) 95-101
    PubMedGoogle Scholar
  • 19 Witlin AG, Mabie WC, Sibai BM. Peripartum cardiomyopathy: an ominous diagnosis. Am J Obstet Gynecol 1997; 176 (1 Pt 1): 182-188
    CrossrefPubMedGoogle Scholar
  • 20 Loftin R, Van Hook J. Peripartum Cardiomyopathy and Pulmonary Edema. Management of Acute Obstetric Emergencies: Elsevier; 2011: 85-92
    Google Scholar
  • 21 Peripartum Cardiomyopathy (PPCM). 2015 [cited 2018 Aug 28]; Accessed August 28, 2018 at: https://www.heart.org/en/health-topics/cardiomyopathy/what-is-cardiomyopathy-in-adults/peripartum-cardiomyopathy-ppcm
    Google Scholar
  • 22 Deputy NP, Dub B, Sharma AJ. Prevalence and trends in prepregnancy normal weight - 48 states, New York City, and District of Columbia, 2011-2015. MMWR Morb Mortal Wkly Rep 2018; 66 (51-52): 1402-1407
    CrossrefPubMedGoogle Scholar
  • 23 Van Tintelen JP, Pieper PG, Van Spaendonck-Zwarts KY, Van Den Berg MP. Pregnancy, cardiomyopathies, and genetics. Cardiovasc Res 2014; 101 (04) 571-578
    CrossrefPubMedGoogle Scholar
  • 24 Wong C, Marwick TH. Obesity cardiomyopathy: diagnosis and therapeutic implications. Nat Clin Pract Cardiovasc Med 2007; 4 (09) 480-490
    CrossrefPubMedGoogle Scholar
  • 25 Kao DP, Hsich E, Lindenfeld J. Characteristics, adverse events, and racial differences among delivering mothers with peripartum cardiomyopathy. JACC Heart Fail 2013; 1 (05) 409-416
    CrossrefPubMedGoogle Scholar
  • 26 Malhamé I, Dayan N, Moura CS, Samuel M, Vinet E, Pilote L. Peripartum cardiomyopathy with co-incident preeclampsia: a cohort study of clinical risk factors and outcomes among commercially insured women. Pregnancy Hypertens 2019; 17: 82-88
    CrossrefPubMedGoogle Scholar
  • 27 Krishnamoorthy P, Garg J, Palaniswamy C. et al. Epidemiology and outcomes of peripartum cardiomyopathy in the United States: findings from the Nationwide Inpatient Sample. J Cardiovasc Med (Hagerstown) 2016; 17 (10) 756-761
    CrossrefPubMedGoogle Scholar
  • 28 Kuklina EV, Callaghan WM. Cardiomyopathy and other myocardial disorders among hospitalizations for pregnancy in the United States: 2004-2006. Obstet Gynecol 2010; 115 (01) 93-100
    CrossrefPubMedGoogle Scholar
  • 29 Pearson GD, Veille JC, Rahimtoola S. et al. Peripartum cardiomyopathy: national heart, lung, and blood institute and office of rare diseases (national institutes of health) workshop recommendations and review. JAMA 2000; 283 (09) 1183-1188
    CrossrefPubMedGoogle Scholar
  • 30 Quan H, Li B, Saunders LD. et al; IMECCHI Investigators. Assessing validity of ICD-9-CM and ICD-10 administrative data in recording clinical conditions in a unique dually coded database. Health Serv Res 2008; 43 (04) 1424-1441
    CrossrefPubMedGoogle Scholar
  • 31 Martin B-J, Chen G, Graham M, Quan H. Coding of obesity in administrative hospital discharge abstract data: accuracy and impact for future research studies. BMC Health Serv Res 2014; 14: 70-70
    CrossrefPubMedGoogle Scholar
  • 32 Wong C, Marwick TH. Obesity cardiomyopathy: pathogenesis and pathophysiology. Nat Clin Pract Cardiovasc Med 2007; 4 (08) 436-443
    CrossrefPubMedGoogle Scholar
  • 33 Timoh T, Bloom ME, Siegel RR, Wagman G, Lanier GM, Vittorio TJ. A perspective on obesity cardiomyopathy. Obes Res Clin Pract 2012; 6 (03) e175-e262
    CrossrefPubMedGoogle Scholar
  • 34 Alpert MA. Obesity cardiomyopathy: pathophysiology and evolution of the clinical syndrome. Am J Med Sci 2001; 321 (04) 225-236
    CrossrefPubMedGoogle Scholar
  • 35 Dela Cruz CS, Matthay RA. Role of obesity in cardiomyopathy and pulmonary hypertension. Clin Chest Med 2009; 30 (03) 509-523 , ix
    CrossrefPubMedGoogle Scholar
  • 36 Lydon-Rochelle MT, Holt VL, Cárdenas V. et al. The reporting of pre-existing maternal medical conditions and complications of pregnancy on birth certificates and in hospital discharge data. Am J Obstet Gynecol 2005; 193 (01) 125-134
    CrossrefPubMedGoogle Scholar
  • 37 Headen I, Cohen AK, Mujahid M, Abrams B. The accuracy of self-reported pregnancy-related weight: a systematic review. Obes Rev 2017; 18 (03) 350-369
    CrossrefPubMedGoogle Scholar
  • 38 Endo D, Morikawa M, Sakakibara M, Sugita T, Yamada T, Minakami H. Extraordinary weight gain: initial finding in a patient with peripartum cardiomyopathy. Case Reports Perinatal Medicine 2014; 3 (01) x
    CrossrefPubMedGoogle Scholar
  • 39 Matsumiya H, Saito N, Minakami H, Kataoka S. Gestational weight gain and peripartum cardiomyopathy in a twin pregnancy. Case Rep Obstet Gynecol 2015; 2015: 317146
    PubMedGoogle Scholar
  • 40 Sakamoto A, Umazume T, Morikawa M. et al. Gestational weight gain in a woman with peripartum cardiomyopathy. Crit Care Obst Gyne 2016; 2 (04) x
    CrossrefPubMedGoogle Scholar
  • 41 Umazume T, Yamada T, Yamada S, Minakami H. Peripartum cardiomyopathy in a woman with preeclampsia with twin pregnancy. BMJ Case Rep 2014; 2014: 2014
    CrossrefPubMedGoogle Scholar
  • 42 Statistics CNCfH. State and Territorial Data. CDC/National Center for Health Statistics [web page] 2017 March 31, 2017; Accessed March 14, 2019 at: https://www.cdc.gov/nchs/fastats/state-and-territorial-data.html
    Google Scholar
  • 43 Leonard SA, Main EK, Carmichael SL. The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity. BMC Pregnancy Childbirth 2019; 19 (01) 16
    CrossrefPubMedGoogle Scholar