Peripartum cardiomyopathy (PPCM) is a rare but potentially life-threatening form of heart failure that occurs toward the end of pregnancy or in the months following delivery in women without pre-existing structural heart disease. It is characterized by left ventricular systolic dysfunction, typically with a left ventricular ejection fraction (LVEF) below 45%, and remains an important cause of maternal morbidity and mortality worldwide [1]. Although the exact etiology remains incompletely understood, proposed mechanisms include angiogenic imbalance, oxidative stress, inflammation, autoimmune responses, genetic predisposition, and hormonal factors, particularly the role of prolactin cleavage products in myocardial dysfunction [2]. The global incidence of PPCM varies considerably, ranging from approximately 1 in 1,000 to 1 in 4,000 live births, with substantial geographic variation attributable to genetic, environmental, socioeconomic, and healthcare-related factors [3]. Higher incidence rates have been reported in certain regions of Africa and Asia, where delayed diagnosis, limited access to specialized cardiac care, and a greater burden of maternal risk factors may contribute to adverse outcomes [4]. Despite advances in cardiovascular imaging and heart failure management, PPCM continues to pose significant diagnostic and therapeutic challenges because its symptoms often overlap with the physiological changes of late pregnancy and the puerperium [5]. In South Asia, PPCM represents a growing public health concern due to increasing maternal age, higher prevalence of hypertensive disorders of pregnancy, anemia, and multiple gestations, all of which have been identified as potential risk factors [6]. The disease burden may be underestimated because of underreporting and limited awareness among healthcare providers, particularly in resource-constrained settings. Early recognition and timely intervention are essential, as delayed diagnosis has been associated with persistent ventricular dysfunction, thromboembolic complications, recurrent heart failure, and maternal death [7]. Echocardiography remains the cornerstone of diagnosis and follow-up in PPCM. It provides valuable information regarding cardiac chamber dimensions, ventricular systolic function, valvular abnormalities, pulmonary artery pressures, and the presence of intracardiac thrombi [8]. Several echocardiographic parameters, particularly baseline LVEF and left ventricular end-diastolic dimensions, have been reported to predict recovery and short-term outcomes. However, considerable heterogeneity exists in the reported echocardiographic profiles and recovery patterns across different populations [9]. India contributes substantially to the global maternal population and continues to face significant challenges related to maternal cardiovascular health. While individual case series and institutional studies have described the clinical presentation and outcomes of PPCM, comprehensive data regarding echocardiographic characteristics and short-term prognosis from Indian tertiary care settings remain limited. Variations in patient demographics, referral patterns, healthcare accessibility, and management practices necessitate region-specific evidence to guide clinical decision-making and optimize maternal outcomes [10]. Given the scarcity of contemporary Indian data and the importance of echocardiographic assessment in prognostication, the present study was undertaken at a tertiary care hospital in India to evaluate the echocardiographic profile of patients diagnosed with peripartum cardiomyopathy and to assess their short-term clinical outcomes. The specific objectives were to describe baseline echocardiographic findings, determine short-term maternal outcomes during follow-up, and explore the association between echocardiographic parameters and clinical recovery.

Study Design: This hospital-based prospective observational study was conducted to evaluate the echocardiographic profile and short-term outcomes of patients diagnosed with peripartum cardiomyopathy (PPCM). The study was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Study Setting: The study was conducted in the Department of Obstetrics and Gynaecology in collaboration with the Department of General Medicine at a tertiary care teaching hospital in India. Study Duration: The study was conducted over a period of one year from October 2024 to September 2025. Patient recruitment, clinical assessment, echocardiographic evaluation, treatment, and short-term follow-up were completed during the study period. Study Population: The study population comprised pregnant women and postpartum women diagnosed with peripartum cardiomyopathy who were admitted to or attended the participating departments during the study period. Inclusion Criteria Women fulfilling all of the following criteria were included: Age ≥18 years. Diagnosis of peripartum cardiomyopathy based on established diagnostic criteria: Development of heart failure during the last month of pregnancy or within five months postpartum. Absence of pre-existing structural heart disease prior to pregnancy. Left ventricular systolic dysfunction demonstrated on echocardiography with left ventricular ejection fraction (LVEF) <45%. Willingness to participate and provide written informed consent. Exclusion Criteria Patients with any of the following conditions were excluded: Known cardiomyopathy prior to pregnancy. Congenital heart disease. Significant rheumatic or valvular heart disease. Ischemic heart disease diagnosed before pregnancy. Chronic heart failure of other etiologies. Incomplete clinical records or inability to complete follow-up. Refusal to provide informed consent. Sample Size: The sample size was calculated using the formula for estimating a proportion: n=(Z^2 P(1-P))/d^2 Where: n = required sample size Z = 1.96 at 95% confidence level P = expected prevalence of PPCM among obstetric admissions d = absolute precision Considering the rarity of PPCM and the limited number of eligible patients presenting during the study period, all consecutive patients meeting the eligibility criteria were enrolled. A total of 46 patients were included in the final analysis, representing complete enumeration of all eligible cases encountered during the study duration. Sampling Technique: A consecutive sampling technique was employed. All eligible patients diagnosed with peripartum cardiomyopathy during the study period and fulfilling the inclusion criteria were recruited until completion of the study duration. Data Collection Tools and Procedure: After obtaining informed consent, detailed demographic, obstetric, clinical, laboratory, and echocardiographic information was collected using a pre-designed, pre-tested structured case record form. Baseline data included age, parity, gestational age, mode of delivery, history of hypertensive disorders of pregnancy, multiple gestation, anemia, and presenting symptoms. Clinical examination findings, laboratory investigations, electrocardiographic findings, and treatment details were documented. Comprehensive transthoracic echocardiography was performed by experienced cardiologists using standard imaging protocols. Echocardiographic parameters recorded included left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), left atrial dimension, presence of mitral or tricuspid regurgitation, pulmonary artery systolic pressure, right ventricular dysfunction, and intracardiac thrombus. Patients received standard medical management as per institutional protocols and contemporary heart failure guidelines. Short-term follow-up was conducted for six months after diagnosis through scheduled outpatient visits and review of medical records. Study Variables: The independent variables included sociodemographic characteristics (age, residence), obstetric variables (parity, gestational age, mode of delivery, multiple pregnancy), clinical characteristics (blood pressure, symptoms, New York Heart Association [NYHA] functional class, comorbidities), and echocardiographic parameters (LVEF, LVEDD, LVESD, valvular regurgitation, pulmonary hypertension, right ventricular dysfunction, and intracardiac thrombus). The dependent variables included short-term clinical outcomes such as recovery of left ventricular systolic function, improvement in NYHA functional class, hospital readmission due to heart failure, thromboembolic complications, and maternal mortality during follow-up. Statistical Analysis: Data were entered into Microsoft Excel and analysed using Statistical Package for the Social Sciences (SPSS) version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) or median with interquartile range, depending on data distribution. Categorical variables were presented as frequencies and percentages. Normality of continuous variables was assessed using the Shapiro–Wilk test. Comparisons between groups were performed using the independent t-test or Mann–Whitney U test for continuous variables and Chi-square test or Fisher’s exact test for categorical variables, as appropriate. Variables demonstrating potential association with outcomes were further evaluated using multivariable logistic regression analysis. A p-value of less than 0.05 was considered statistically significant. Ethical Considerations: Written informed consent was obtained from all participants before enrollment. Confidentiality and anonymity of participant information were maintained throughout the study by assigning unique identification numbers and restricting access to study data. Participation was entirely voluntary, and patients were free to withdraw from the study at any stage without affecting their medical care. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its subsequent amendments.

Table 1. Baseline Sociodemographic and Obstetric Characteristics of Study Participants (n=46) Characteristic Frequency (n) Percentage (%) Age group (years) ≤25 15 32.6 26–30 18 39.1 >30 13 28.3 Mean age (years), Mean ± SD 28.4 ± 4.6 — Residence Rural 29 63.0 Urban 17 37.0 Parity Primipara 19 41.3 Multipara 27 58.7 Multiple pregnancy 6 13.0 Hypertensive disorder of pregnancy 15 32.6 Mode of delivery Vaginal delivery 20 43.5 Caesarean section 26 56.5 Timing of diagnosis Antepartum 9 19.6 Postpartum 37 80.4 A total of 46 women diagnosed with peripartum cardiomyopathy were included in the study. Most participants were aged 26–30 years, multiparous, and from rural areas. More than four-fifths of the cases were diagnosed during the postpartum period, while hypertensive disorders of pregnancy were present in approximately one-third of patients (Table 1). Dyspnoea was the most common presenting symptom, followed by pedal edema and orthopnoea. The majority of patients presented with NYHA class III symptoms. Echocardiography demonstrated marked left ventricular systolic dysfunction, with a mean LVEF of 31.8%, accompanied by ventricular dilatation. Mitral regurgitation was the most frequent associated echocardiographic abnormality (Table 2). Table 2. Clinical Presentation and Echocardiographic Profile at Diagnosis (n=46) Variable Value Clinical presentation n (%) Dyspnoea 44 (95.7) Pedal edema 35 (76.1) Orthopnoea 24 (52.2) Palpitations 18 (39.1) Chest discomfort 10 (21.7) NYHA Functional Class Class II 11 (23.9) Class III 25 (54.3) Class IV 10 (21.7) Echocardiographic parameters Mean ± SD Left ventricular ejection fraction (LVEF, %) 31.8 ± 6.9 LV end-diastolic diameter (LVEDD, mm) 61.7 ± 6.4 LV end-systolic diameter (LVESD, mm) 50.9 ± 5.8 Left atrial diameter (mm) 41.3 ± 4.5 Pulmonary artery systolic pressure (mmHg) 41.8 ± 9.6 Additional echocardiographic findings n (%) Moderate/severe mitral regurgitation 20 (43.5) Tricuspid regurgitation 16 (34.8) Right ventricular dysfunction 9 (19.6) Intracardiac thrombus 3 (6.5) At six-month follow-up, slightly more than half of the patients demonstrated recovery of left ventricular systolic function, while approximately two-fifths continued to have persistent ventricular dysfunction. Improvement in functional status was observed in over two-thirds of patients. Heart failure-related readmissions, thromboembolic complications, and maternal deaths occurred in a minority of cases (Table 3). Baseline echocardiographic parameters showed significant associations with recovery. Patients with baseline LVEF ≥35% had significantly higher rates of recovery compared with those having LVEF <35% (p=0.008). Similarly, patients with LVEDD ≤60 mm were more likely to recover ventricular function than those with larger ventricular dimensions (p=0.019) (Tables 4 and 5). Table 3. Short-Term Outcomes at Six-Month Follow-Up (n=46) Outcome Frequency (n) Percentage (%) Recovery of LV systolic function (LVEF ≥50%) 24 52.2 Persistent LV dysfunction 19 41.3 Heart failure readmission 7 15.2 Thromboembolic event 2 4.3 Maternal mortality 3 6.5 Improvement by ≥1 NYHA class 31 67.4 Table 4. Association Between Baseline LVEF and Recovery of Left Ventricular Function at Six Months Baseline LVEF Recovered (n=24) Not Recovered (n=22) p-value ≥35% (n=20) 15 (75.0%) 5 (25.0%) 0.008* <35% (n=26) 9 (34.6%) 17 (65.4%) *Chi-square test; p < 0.05 considered statistically significant. Table 5. Association Between Baseline LVEDD and Recovery of Left Ventricular Function at Six Months Baseline LVEDD Recovered (n=24) Not Recovered (n=22) p-value ≤60 mm (n=21) 15 (71.4%) 6 (28.6%) 0.019* >60 mm (n=25) 9 (36.0%) 16 (64.0%) *Chi-square test; p < 0.05 considered statistically significant.

The present prospective observational study evaluated the echocardiographic profile and short-term outcomes of 46 women diagnosed with peripartum cardiomyopathy (PPCM) at a tertiary care hospital in India. The study demonstrated that PPCM predominantly affected young women in the postpartum period and was characterized by significant left ventricular systolic dysfunction at presentation. More than half of the patients achieved recovery of left ventricular function during six months of follow-up, while persistent ventricular dysfunction remained common. Importantly, higher baseline left ventricular ejection fraction (LVEF) and smaller left ventricular end-diastolic diameter (LVEDD) were significantly associated with recovery, highlighting the prognostic value of echocardiographic assessment in PPCM. In the present study, the mean age of participants was 28.4 years, and the majority were multiparous. Similar demographic characteristics have been reported in the worldwide registry of PPCM and several observational studies, where affected women were commonly in their late twenties to early thirties [4,10]. Although advanced maternal age has been identified as a risk factor in some populations, PPCM frequently affects younger women in low- and middle-income countries, reflecting differences in reproductive patterns and population demographics [5]. The predominance of multiparous women in our cohort is also consistent with previous reports suggesting cumulative physiological stress from repeated pregnancies as a potential contributing factor [7]. More than 80% of patients in the present study were diagnosed during the postpartum period. This finding is consistent with previous literature indicating that PPCM most commonly presents within the first few weeks after delivery [1,5]. The postpartum predominance may be explained by hemodynamic shifts, hormonal changes, oxidative stress, and inflammatory mechanisms that become more pronounced following childbirth [2]. Clinically, dyspnoea was the most frequent presenting symptom, followed by pedal edema and orthopnoea. Similar symptom profiles have been consistently reported across international registries and observational studies [4,11]. Because these manifestations often overlap with normal physiological changes of late pregnancy and the puerperium, delayed diagnosis remains an important clinical concern. Echocardiographic evaluation revealed marked left ventricular systolic dysfunction with a mean LVEF of 31.8% and evidence of ventricular dilatation. Moderate-to-severe mitral regurgitation was the most common associated echocardiographic abnormality. These findings are comparable to those reported by Blauwet et al. and other investigators who observed severe impairment of systolic function and varying degrees of secondary valvular regurgitation at diagnosis [9,12]. Echocardiography remains the cornerstone for both diagnosis and prognostication because it provides objective assessment of ventricular function, chamber dimensions, and associated structural abnormalities [8]. The recovery rate of 52.2% observed in the present study falls within the range reported by previous cohorts, where recovery rates between 40% and 70% have been documented depending on follow-up duration and baseline disease severity [13,14]. While most patients experienced improvement in functional status, a substantial proportion continued to demonstrate persistent ventricular dysfunction, underscoring the heterogeneous nature of PPCM. The observed maternal mortality rate of 6.5% is comparable to rates reported from several developing-country settings but remains higher than those documented in many high-income countries, likely reflecting differences in healthcare access, referral patterns, and disease severity at presentation [4,15]. One of the most important findings of the present study was the significant association between baseline echocardiographic parameters and subsequent recovery. Patients with baseline LVEF ≥35% were significantly more likely to achieve recovery than those with more severe systolic dysfunction. Similarly, smaller baseline LVEDD was associated with favorable outcomes. These observations are in agreement with previous studies demonstrating that baseline ventricular function and chamber dimensions are among the strongest predictors of recovery in PPCM [9,13,16]. Women presenting with less advanced myocardial remodeling may possess greater myocardial reserve and a higher likelihood of reverse remodeling following initiation of appropriate therapy. The findings of this study have important clinical implications. Early echocardiographic evaluation should be prioritized in women presenting with symptoms suggestive of heart failure during late pregnancy or the postpartum period. Identification of high-risk patients based on echocardiographic parameters may facilitate closer monitoring, timely initiation of guideline-directed medical therapy, and improved counseling regarding prognosis and future pregnancies. Furthermore, strengthening collaboration between obstetricians, cardiologists, intensivists, and primary care physicians may contribute to earlier diagnosis and improved maternal outcomes. The strengths of this study include its prospective design, standardized echocardiographic assessment, and systematic short-term follow-up of all enrolled patients. The study also provides contemporary data from an Indian tertiary care setting, where evidence regarding PPCM remains relatively limited. However, several limitations should be acknowledged. The study was conducted at a single tertiary care center, which may limit generalizability to other populations. The relatively small sample size reflects the rarity of PPCM and may have reduced statistical power for identifying additional predictors of outcome. Follow-up was limited to six months; therefore, long-term recovery patterns and subsequent pregnancy outcomes could not be evaluated. In addition, advanced imaging modalities such as cardiac magnetic resonance imaging and assessment of circulating biomarkers were not routinely performed. Despite these limitations, the present study contributes valuable evidence regarding the echocardiographic characteristics and short-term outcomes of PPCM in an Indian population. The findings reinforce the central role of echocardiography in risk stratification and support the importance of early diagnosis and multidisciplinary management to improve maternal prognosis.

Peripartum cardiomyopathy remains an important cause of maternal cardiovascular morbidity and mortality, particularly in resource-constrained settings. In the present study, most patients presented during the postpartum period with symptomatic heart failure and significant left ventricular systolic dysfunction. Echocardiographic evaluation revealed reduced left ventricular ejection fraction and ventricular dilatation as common findings. Although more than half of the patients demonstrated recovery of left ventricular function within six months, a substantial proportion continued to have persistent ventricular dysfunction, highlighting the variable clinical course of the disease. Baseline echocardiographic parameters, particularly left ventricular ejection fraction and left ventricular end-diastolic diameter, were significantly associated with recovery and may serve as valuable prognostic indicators. Early recognition of symptoms, prompt echocardiographic assessment, and multidisciplinary management are essential for improving maternal outcomes. Strengthening awareness among healthcare providers and ensuring timely referral of suspected cases may facilitate earlier diagnosis and intervention. Further multicentric studies with larger sample sizes and longer follow-up are recommended to better understand long-term outcomes and optimize management strategies for women with peripartum cardiomyopathy.

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