 Talk about cardiomyopathy in pregnancy and I love this topic because there's some neat new stuff happening I'm going to stay on topic if I can So Rihanna went through this schema of what happens in pregnancy This is super important when we talk about cardiomyopathy Because cardiomyopathy can come in all flavors The one you think about in pregnancy is you think a peripartum cardiomyopathy, right? Well, I'm just going to cut to the chase at the beginning of this talk because this slide super important so early on at Early stage of pregnancy You get a ramp up when the fetus is you know less than 12 weeks. The baby's this big It's not giving you much hemodynamic demands unless it's making you so sick that you can't Get your hemodynamics in in line because you're so dehydrated and we see women like that They need to be admitted for fluids. Okay, but in general the first trimester of pregnancy your body's just Kind of getting used to there's something weird going on in my body The second trimester there's a serious ramp up because the baby starts to actually grow to be a size That actually has some hemodynamic Compromise on the maternal system. So during the second trimester. There is this ramp up in Volume okay, so how does your heart? Manifest the the skill sets it's required to You know nourish a fetus that's got a require 40 to 50 percent extra blood volume Okay, and it does it by several mechanisms one the placenta itself has low vascular resistance because that Circuitry is open right the blood vessels between mom and baby or like full-on baby steals from you Okay, that drops the overall vascular resistance all the way through pregnancy In fact vascular resistance goes up pretty dramatically when you take the placenta out at birth. Okay, the stroke volume Volume that's in the blood vessels climbs dramatically and peaks really at like 30 weeks of gestation So during this period of the second trimester Babies not that big but the hemodynamic effects of that baby are pretty pretty juicy And I see quite a few number of quite a few patients who are pregnant. Mostly they're sinking Consultation in the second trimester because they have symptoms of I'm short of breath. I have palpitations Really 90% of these patients really just have symptoms of this stress to their cardiovascular System, but this is important the stress of the cardiovascular system really puts the Heart under stress in the second trimester. Okay, so if you've got a problem with your heart You're gonna show up with shortness of breath palpitations Hypoxic heart failure in the second trimester if there's something wrong with you So one of the reasons that I get to see so many of these like Hopeful young and healthy patients Which I love to see on Fridays because it reminds me of what the world's really like before the weekend that They are easy to fix because well, there's nothing wrong with them. You make sure they're heart structurally normal and that their blood pressure is good They don't have any other cardiac Concerns and they're just back to the OBGYN with a bunch of reassurance and a copy of their echocardiogram report And that they don't have WPW and they're gone They don't come back to you. You just tell them to make sure they drink a lot of fluid stay off their side and they're good So second trimester is when you show up if you have an abnormality of your heart But peripartum cartomyopathy usually presents in like 80 to 90 percent of the cases within one month of delivery Okay, so if you had something wrong with your heart early on These patients would have shown up earlier So the timing of the presentation kind of helps to tease out. What's the cause of the heart failure? It's not perfect, but it's kind of good. So what about heart failure and pregnancy? Well, heart failure and pregnancy is really quite rare as I said Most of these patients are just normal and they're having physiological changes that are Manifesting as shortness of breath about 60 to 70 percent of pregnant women complain of shortness of breath I mean, it's just a fact that when you're pregnant You're mostly going to have people that are short of breath and you're gonna have to figure out when to get worried Okay, some people get worried earlier than we do because we're used to kind of seeing a lot of badness But the output of the cardiac out it goes up in the last stages of pregnancy which increases the risk for heart failure So in patients with pre-existing cardiomyopathy Idiopathic or what we call dilated, but it doesn't have to be dilated Infectious valvular or drug associated like you've had the anthra cyclins or HRA myosin That's the most common cause of heart failure and pregnancy Actually, probably the most common cause of heart failure and pregnancy is you're a normal person and somebody gave you way too much salt Somewhere close to delivery, but your function of your heart is normal. Okay? The timing of decompensation I've just explained if it occurs in the second trimester or early It's usually that you've got a pre-existing cardiomyopathic process because pericardium cardiomyopathy is Almost always the last trimester with the really the lat the month the last month of pregnancy So what about pre-existing cardiomyopathies? Well, this is actually important because as women have grown older in the child birthing process now women are have come and because the congenital heart disease surgery and Treatment has become so good women that previously would have never had a baby or now having babies with IVF Okay, and congenital heart disease. I mean we have fontan's that get pregnant now And in the olden days, you know fontan patients didn't get a fontan They didn't even survive into adulthood and now we have these people that are now Paliated and have abnormal hearts that really want to have a baby and you know the IVF people they're more than willing to Respond to that so we've got an excess risk of patients that really drive the risk For maternal mortality as women have gotten older for multiple reasons So primary or dilated cardiomyopathy Are have symptoms of heart failure obviously and evidence of elderly systolic dysfunction Without evidence of abnormalities and hypertrophy, so they're not a hypertroph and they're not a dilated cardiomyopathy And they are a no valve disease usually patients that have Class 2 to 4 heart failure Develop have an EF less than 45% and are at the greatest risk for decompensation and these women should avoid pregnancy So if the EF pre-pregnancy is less than 45 they should not get pregnant. Okay a woman However, that shows up Pregnant with an EF less than 20 should have the pregnancy terminated. Okay, because the volume of pregnancy 40 to 60% Increase is going to be very bad on a heart. That's already not able to sustain life for the mother Okay, those dilated cardiomyopathies are really Unfortunate, okay, and you usually know that the patient has it every now and then we get a hypertroph That's pregnant and they didn't know they were a hypertroph. Okay, they may not have known they had a family history It may be a sporadic mutation But remember hypertrophic cardiomyopathy is an autosomal dominant condition one in 500 white people carry the gene It's common. Okay, many people don't even know they have it Okay, the definition of hypertrophic cardiomyopathy I put this in for you Dr. Livesey is that you have unexplained hypertrophy Okay in any wall it doesn't have to just be the septum. You probably heard of the term ash or asymmetric septal hypertrophy That is one Variant of hypertrophic cardiomyopathy, but any level of hypertrophy that's unexplained meaning It's not because you had high blood pressure or aortic stenosis or VSD or coarctation It's unexplained is usually a phenotypic expression of hypertrophic cardiomyopathy remember that the abnormalities of diastolic function occur in the absence or before people get hypertrophy and the diastolic abnormalities become a phenotypic expression of There's something wrong with my heart So if you're looking to screen family members with hypertrophic cardiomyopathy The thing we look for is hypertrophy and abnormalities of diastolic performance Okay, not genetic testing, right? It's the echo So what are the symptoms of hypertrophic cardiomyopathy? Well, they depend on several things the pattern of hypertrophy So if the septum is predominantly hypertrophy, it will produce the most outflow track abnormalities Which will produce the most obstruction Mitra regurgitation the worst diastolic dysfunction and the most symptoms early apical hypertrophs generally have Hypertrophy limited to the apex which really go kind of unnoticed People show up with apical hypertrophic cardiomyopathy because they have a funny EKG Honestly the EKG's that Eunice showed that one today with the deep T-wave inversions And I wasn't paying attention because I was taking notes And then I looked up and I saw the EKG and the first thing I thought of was well because I'm not a coronary Maven is I thought oh my god Do they have apical hypertrophic cardiomyopathy because that's a typical pattern So if you see an EKG like that and the and the echo doesn't show much concentric hypertrophy The apex may not be showing you how much hypertrophy there really is you may need Contrast a better echocardiographer or an MRI. Okay, so the severity of the outflow track obstruction Determined symptoms the severity of the diastolic dysfunction which tells you something about the the longevity of the diastolic abnormalities and or the significance of the outflow track obstruction and Whether or not they have a fib okay a fib and VT are Certainly Then a cause symptoms and late systolic dysfunction is very it's really uncommon in Hypertrophic cardiomyopathy in fact most people that have hypertrophic cardiomyopathy have a normal life expectancy Because they don't really get systolic dysfunction until very late in the pathway pregnant women with hypertrophic cardiomyopathy may present with new onset symptoms of heart failure or rythmia or an Asymptomatic murmur of outflow track obstruction in pregnancy. This was actually a question on the boards I had to retake recertify for the boards this year and all the fellows walked out Talking about this question about the hypertrofe who was pregnant and the question they asked on the board I can't remember the whole thing, but it was something like Patient is symptomatic with out with hypertrophic cardiomyopathy. Do you terminate the pregnancy? Is this well, you know? Symptoms are well controlled in pregnancy and I was like, oh my god, it's a hypertrofe What happens in hypertrophs hypertrophs have a problem when the ventricles really small, but pregnancy increases the volume of 40 to 60 percent So what do you think normally happens in pregnancy hypertrophs get better? They get a bigger volume. They have less outflow track obstruction and really you don't need to worry about the patient That's a hypertroph in pregnancy unless they have something really critical So in general, they handle pregnancy quite well The only problem is they're just given their genetic code to the fetus and they've got a 50-50 chance of yielding these hypertrophic genes so Patients that are hypertrophs have an increased risk of sudden death Heart failure and stroke the high-risk features are a History of sudden cardiac arrest or ventricular arrhythmia Severe hypertrophy greater than three centimeters and a family history of sudden cardiac death Unexplained syncope now we get all excited in the cardiology world about unexplained syncope even in hypertrophs But it's generally that they a got dehydrated or they took too many medications But they certainly definitely need a workout non-sustain ventricular tachycardia and people younger than 30s and age at Presentation less than 30 is certainly an increased risk. So I already gave away the speech, you know pregnancy does well with hypertrophic cardiomyopathy because High pregnancy and proves the hemi dynamics that favor better outflow emptying in in patients that have Hypotropic cardiomyopathy Okay, now we get to the big guy the big daddy acquired peripartum cardiomyopathy and why is it important? Well, there's a lot of research going on about peripartum cardiomyopathy because it can be quite lethal If you miss it The definition is that you have to have symptomatic heart failure. So you have to have Shortness of breath rals Hypoxia, etc. You have to have and this is important the original definition of peripartum cardiomyopathy 1971 okay, it wasn't like a hundred years ago. We're talking 40 years ago not that many years ago that people first described peripartum cardiomyopathy At that time they were just diagnosing it as symptomatic heart failure and it included a big category of like anybody who got salt-loaded You get it Working group in 1991 decided, you know, we need to put a limitation on the EF and they mandated that the Cystallic function had to be abnormal to be able to call it Peripartum cardiomyopathy and you can't have any other reason for heart failure Meaning you can't have the Barlow valve or a bicuspid aortic valve or hyper traffic cardiomyopathy or previous cardiomyopathy or hyper thyroid So the key and this is important the definition for peripartum cardiomyopathy is by definition a broad definition Okay, you can see it's not like to pedantic the onset of symptoms is Really related to how severe is the myopathic process and how rapidly did it decline decline? Okay, so if you have a really really bad acquired Cardiomyopathy and pregnancy that occurs earlier in the pregnancy it may still be peripartum cardiomyopathy You see what I'm saying. You just don't have a snapshot of what this woman looked like before and And the outcomes between early onset peripartum and late onset peripartum. They're the same so It's usually and I think I'll have a slide here I'm gonna show it in a second where you see all the cases of peripartum cardiomyopathy Presenting right around the month of delivery But if you have a patient that fits the bill early on and they didn't have any symptoms before They may still be a peripartum cardiomyopathy. It's really a diagnosis of exclusion Okay, so the symptoms of heart failure without any underlying heart failure Non-invasive imaging you must show a documentation of a reduction in the EF. It's usually done by echocardiography I mean people aren't really too eager to put pregnant people in the CT scanner We put people in them in the MRI with impunity. Here's the slide. I was looking for it This is a complicated slide because this shows weeks of gestation These blue dots are the incidence of peripartum cardiomyopathy You can see like the lion's shear is within one to four weeks of delivery So it's usually really a good name peripartum cardiomyopathy because part of means delivery these slides also show you in black the changes the hemodynamic changes that occur in pregnancy and Clearly you can see that these hemodynamic changes have vigorously Predated the onset of the cardiomyopathy. So it's hard to say that The hemodynamic stress is what caused the cardiomyopathy, right? The hemodynamic stress may unmask the cardiomyopathy if somebody has a secondary cause or another cause for cardiomyopathy But you would expect that to be unmasked way back here, right? Cool, then the second thing that this shows is the levels of prolactin in the soluble Marker that's both of these hormones are presumed to be involved in the etiology of peripartum cardiomyopathy and this slide shows the development In the increase of these hormones prolactin comes from the pituitary gland and this soluble tyrosine Molecule comes from the placenta and so you can see that these levels rise predating the Development of cardiomyopathy and fall rapidly after delivery, which some believe Maybe part of the reason why so many of these patients with peripartum cardiomyopathy recover from cardiomyopathy because the ascending Ideological agents are being removed naturally by the body after pregnancy Okay, so what's the incidence of peripartum cardiomyopathy? Well, guess what it a core it varies quite a lot based on geography and socioeconomic class and by race So the lowest incidence in the world is in Japan one in twenty thousand It's the highest in Nigeria and Haiti for a lot of reasons But as high as one in a hundred mean we are talking a lot of peripartum cardiomyopathy The US in general we think it's about one in four thousand, but it's increasing Why is it increasing? Ah Multiple gestations preeclampsia older age Those are the things that increase it so the incidence is increasing it used to be about eight and a half cases per Ten thousand now it's up to almost twelve and two thousand eleven Possibly related to we have more awareness. We're not ignoring women Because if you ignore them and they have a mild cardiomyopathy They may just get better on their own and you never knew they had a peripartum cardiomyopathy, right? You might not know There's a lot more access to diagnostic imaging. Tell me about it We got people in this hospital running around with diagnostic echoes that are this big. I need one Advanced maternal age multiple gestation and preeclampsia on the rise the highest risk group are women who are over 30 We're old African Americans people with preeclampsia hypertension and multiple gestations so 50% of peripartum cardiomyopathy occur in women over 30 years of age and People over 40 years of age when they have a baby are at a tenfold increased risk of peripartum cardiomyopathy Compared to somebody age 20 or less So globally if we look at meta-analysis because there aren't enough big centers with cardiomyopathy In pregnancy, okay, they're just they're just not so what they've done is they've cobbled together some consortium the biggest meta-analysis includes 979 women with peripartum cardiomyopathy and they found that preeclampsia was prevalent in about 22% of the population that had Peripartum cardiomyopathy, which is about four to five times what you'd expect in the background population The prevalence of hypertension was 37% which is quite high and in this global analysis There was not that much of an association with race or gender when they looked at the same Factors in the United States they had 535 women in a cohort in six states and they showed similar rates of preeclampsia and hypertension Which pretty much tells you that there's something with the hypertensive mom that leads to or Influences the likelihood of being susceptible to peripartum cardiomyopathy The thought is that preeclampsia is associated with the predisposition to cardiomyopathy through a shared path of physiologic mechanism That's independent of race and geography So what I love this slide the most because it took me so long to figure it out. I had to I Had to write a book chapter for dr. Willerson and I was went a little crazy on this section because well it's so entertaining and there's so many new findings and It hasn't an impact on how we might treat women so being a woman provider and there's so few women heart doctors We're 12% that we need to know every I felt like I had to know everything about it So I tried to learn everything so he met an amic stress is considered to be Originally one of the reasons why peripartum cardiomyopathy was cause I don't buy that at all because the presentation doesn't fit with It just doesn't fit with the outcome Selenium deficiency is actually probably a cause for cardiomyopathy in Sub-Saharan Africa because of nutrients And that may compound the reason why Some African nations have such high levels of peripartum cardiomyopathy, but when it's been looked in Third non-African sub-Saharan country Selenium deficiency is not a cause for peripartum cardiomyopathy in our part of the world Genetics probably plays a role Probably plays a role by providing the substrate for which whatever the second hit comes along in influences Most women that have peripartum cardiomyopathy have no family history of peripartum cardiomyopathy or any kind of a dilated cardiomyopathy However, there are small familial clusters of peripartum cardiomyopathy and they cluster with dilated cardiomyopathy there may be a genetics susceptibility in a subset of African-American or Women of African descent and then there's this whole thing about a titan gene, which is a sarcomere protein that Influences the risk for peripartum peripartum cardiomyopathy. That's not associated with hypertension So peripartum cardiomyopathy may be the subset of a big group and there may be multiple ideologies, right? That's what I'm beginning to think the thing that you need to know is there's probably some input impact of Hormones that are coming from the mother either from her Pertuitary gland or from her placenta that interact in susceptible hosts the right the mom with the right genetic code To induce vascular injury. Okay, the vascular injury is what leads to the cardiomyopathy now Remember that at birth The mom has to go from having a hormonal milieu that's Eager for blood to move so no clotting you go from a I'm not going to clot in this blood vessel too I got a clot because I'm if I don't clot when I deliver this baby I'm going to bleed to death and there are triggers in the maternal circulation That turn the switch is off so that the mom's body is getting ready to deliver Okay, so this angiogenic balance Can be local in the placenta or in the heart or it can be coming from the pituitary gland for the whole body So the thought is that there are these anti angiogenic factors That have been documented in two mouse models I swear to cause cardiomyopathy Experimentally in addition we know that the anti-veg F chemo therapy. I can't say the name But it's a vastan. That's the name you can say beva This a map. I did it is an anti-veg F chemo therapeutic agent used for breast ovarian lung cancer Leads to cardiomyopathy. Okay, so there is experimental evidence that if you block veg F You can induce a cardiomyopathy in in men and in women So what are the two anti-angiogenic hormones that are present in the maternal circulation that peak at the end of pregnancy? Well once prolactin in one soluble variant of the vascular endothelial growth factor of veg F Which comes from the placenta these levels of the soluble veg F Receptor variant are increased in women with pericardium cardiomyopathy They're increased in preeclampsia and they're coming from the placenta So if you have multiple gestations, you have multiple placenta, you know bigger placenta, you're making more of this stuff The levels are correlated with heart failure symptoms and outcome in women with pericardium cardiomyopathy in the most important study of pericardium cardiomyopathy which is called IPAC which was between it was a friend of mine who started the study at the Toronto Hospital and they've enrolled a hundred women and prospectively followed them with serial Timely echoes and we're going to talk about them in a minute, but the hormonal vascular theory in pericardium cardiomyopathy such that these hormones Once they're emitted into this central circulation they set up a cascade of chemical factors that lead to apoptosis Capillary dissociation and vasoconstriction. Okay, and if you block the chemicals with bromocryptin or you rescue the animal with lot with Veg F you can reverse the cardiomyopathy. Okay, so There's hope for one of the other things I want to say is first thing that women do when they deliver a baby if they have a terrible cardiomyopathy and they have terrible heart failure is they Stop breastfeeding. Okay, because they're too sick to breastfeed and Stopping the breastfeeding may actually drop the prolactin levels and aid in the recovery of these patients Okay, what are the prognosis? Well, the maternal risks are death cardiac arrest need for heart transplantation mechanical circulatory support to get you over the hump Fulminant heart failure and thromboembolic events. I mean really you can die Retrospective review showed that 36% of women that develop hericardom cardiomyopathy Experienced a major adverse cardiac event. So it's serious stuff The IPAC is this prospective study of a hundred women followed for 12 months 13% of these women had a major Vascular event or persistent cardiomyopathy with an EF less than 35 the good news in IPAC was that 72% of these women had complete recovery And if you recover and you're not African-American you recover quickly Okay So what about the mortality mortality rates vary because of the the racial pattern of Peripartum cardiomyopathy. So in the US in hospital mortality is only 1.3% But after seven to eight years of follow-up, it may be as high as 16% So you may get out of the hospital, but you've been left with a smoldering cardiomyopathy process It's a leading cause of maternal death in California with a basically a quarter of the death and the prognostic Adverse risk factors for maternal death include a higher New York Heart Association classic EF less than 30 African-American race and age over 30 So neonatal and obstetrical outcomes, they're abnormal to 40% of women that have it got a C-section Stillbirth occurred in almost 4% in IPAC. There were two 2% stillbirths one neonatal death and four babies with congenital anomalies They have lower mean birth weights at bar scars and the timing of delivery is just based on how's the mom and the baby doing So LV recovery is super important So LV recovery and peripartum cardiomyopathy is greater in women with peripartum than a non peripartum cardiomyopathy Peripartum we with the way we look at peripartum. I are cardiomyopathy is that if you have it It's better than having a regular cardiomyopathy if you don't die from it right up front because you're more likely to recover Partial or complete recovery it depends on the group that you're looking at in IPAC. It was 72% but in a cohort from South Africa, it was only 42% but that was predominantly an African Black genetic Predisposition so in IPAC study, that's American and Canada Canadian prospective study We talked about it 13% had adverse events in one year 15% had a partial recovery and 72% recovered completely So I mean mostly they do pretty well Most recover fully within six months. In fact 75% of those that recover fully do so Within the first two months. So if you're watching the patient, you should watch them recover kind of quickly The predictors of recovery the most important predictor of recovery is what's the EF at presentation? If the EF is if the EF is less than 30 or the LV dimension is greater than six They have a low rate of recovery But if they have it better than sit less than six and greater than 30 91% improved so poor recovery low EF less than 30 in internal dimension of the LV and diastole of six a late diagnosis LV thrombus or black race are Risk factors for poor recovery. So here's the comment about the LV ID in the EF So if you have a good LV ID and an EF greater than 30 full recovery occurs in 91% if you have neither No one gets a full recovery So you can tell at the very beginning when you see the woman what the prognosis is based on echocardiographic measurements at the time you make the diagnosis if the EF is greater than 30 at presentation You have an 86% full recovery compared to those with an EF less than 30 37% in the lowest EFs at presentation 30% of women failed to recover to over 30% and 63% failed to recover over 50% But see even in that very very poor EF group 10 to 20% 37 of those percent of those women completely recovered, okay So what about relapse? With subsequent pregnancy so there these are women and peripartum cardiomyopathy May occur with the first pregnancy If the heart completely recovers the next thing she's gonna ask is when can I have another baby? And I understand that because I have two children. I'm not sure I could do more But relapse rates or a decline in the LV EF double or double when women fail to recover So if you have a woman who fails to recover her EF greater than 50 her risk of having a decline in her EF from whatever she is is 48% Okay, the mortality in this group may be as high as 16% and that's in America in other countries It may be quite a bit higher. Okay, but normalization of EF does not predict a risk-free second pregnancy Many people still go on to develop heart failure and a quarter of them had a fall in the EF more than 20 points So what about the treatment for peripartum cardiomyopathy? How am I doing? It's basically follow the guidelines for regular cardiomyopathy treatment diuretics IV or oral vasodilators so in African Americans that may be hydrolyzing and and and nitrates If the patient is no longer pregnant and not breastfeeding it may it should include ACE inhibitors They're ARB's beta blockers can be given for women that are not in full men and heart failure Mineralic corticoid inhibitors are okay, and the joxin is still used although We don't really think it does much good, but the OB's love it The key is to treat to improve stroke volume and cardiac output. The joxin use is safe in pregnancy It's not that useful, but you may need a higher dose because of the volume of distribution and pregnancy And then I think I'm gonna just show you a pretty picture of what a clot looks like So peripartum cardiomyopathy Certainly when it's severe has a higher risk of clotting because the pregnancy state is all You know thromboembolic milieu for clotting. So these women need basically happen until they deliver Or until the clot is gone and the EF has improved the risk for stroke is You know between 1 and 12% Embolic events are real and since it occurs the peripartum cardiomyopathy occurs a clay is late in pregnancy We really kind of like to use heparin because you can turn it on and turn it off Postpartum you may want to use warfarin Important to note because we're going to talk about novel treatments that bromocryptin Which will inhibit the really the conversion of prolactin from the pituitary gland to an active in Compelling hormone was used in the 70s and is was free on the market to help dry up the mother's milk And it was associated with an increased risk of stroke and heart attacks and for that reason it really isn't used today Okay So you've got a drug that you might think might be beneficial for pregnant women with peripartum Cardiomyopathy you need to think if you use it. Maybe it has some hypercoagulable properties So that brings us to the slide that talks about possibly in the future people are experimenting with using bromocryptin no Randomized trials have been done. There were two trials from Germany and in neither trial. Was there a confident control group so Quite honestly if I had a patient that was critically ill and all the therapies were failing would I pull out the bromocryptin? beyond it out so The other important thing is that after recovery and you're on a woman with a woman with recovery of LV function on Cardiomyopathy medications the rule is that the woman should stay on the medicines for at least 12 months after the presentation and For six months following complete LV recovery and then the medication should be withdrawn one at a time While surveying the symptoms and annually looking at the echo to make sure that the function of the heart is Still okay If you said to me she's doing well on the medicines should we leave them on the medicines? I'm okay with that too The only other important thing is that because these Cardiomyopathy's tend to improve if they're going to quite rapidly before an AICD is put into the patient at a young age, which is going to require a lot of battery changes and a lot of Extra cost you might consider wearing a life vest to assess and the treat for lethal arrhythmias if you think that the function of the heart is going to improve I think Delivery is really just based on the needs of the baby and the mom. I think I'm going Breastfeeding and I'm over time breastfeeding has actually been looked at as a culprit for not a good risk for the mom with continued prolactin levels, but Overall the message from the WHO Which is basically going to support women who are breastfeeding in third-world nations where there's no other food for babies Has come out with a consensus statement saying that breastfeeding should be continued because in some countries no breastfeeding means baby may not survive So most people with pericardium cardiomyopathy get better on their own anyway Only in the ones that are very severely Impaired would I recommend that the breastfeeding be stopped and remember that ARB should be avoided because they are excreted in the breast milk and Remember that in women that are postpartum from a pericardium cardiomyopathy They are still at increased risk for thromboin and embolic events And we should recommend contraceptive devices that are non estrogen containing so maybe progestin depot or IUDs or Sterilization are recommended in these women. I think I'm going to turn it over there and I'm so sorry. I went over a little bit All right that we're supposed to take away