Abstract
BACKGROUND: Peripartum cardiomyopathy (PPCM) is a rare, potentially fatal form of systolic heart failure occurring in late pregnancy or early postpartum, typically without prior structural heart disease. In India, its incidence is estimated to be 1 in 1374 live births, with maternal mortality up to 15% in resource-limited settings. When coexisting with preeclampsia, PPCM presents diagnostic and therapeutic dilemmas. Although bromocriptine is supported by trials and European Society of Cardiology (ESC) guidelines, its use in India remains limited, especially in hypertensive pregnancies due to safety concerns. CASE PRESENTATION: We describe three antenatal patients with PPCM and severe preeclampsia managed at a tertiary referral hospital. All had moderate-to-severe left ventricular dysfunction (left ventricular ejection fraction LVEF 25-35%). One, treated without bromocriptine, had persistent dyspnoea and LVEF < 45% at two weeks postpartum. Two others received bromocriptine (2.5 mg daily); one initiated early showed full recovery (LVEF 60% by day 14), while the other, started on day 8 postpartum, showed partial recovery (LVEF 50%). DISCUSSION: The series underscores the importance of early echocardiography in distinguishing PPCM from preeclampsia-induced pulmonary oedema. It supports the "two-hit hypothesis", where preeclampsia acts as a second insult, triggering oxidative stress and formation of a cardiotoxic 16-kDa prolactin fragment. Bromocriptine, by inhibiting prolactin, may interrupt this pathogenesis. CONCLUSION: Early recognition of PPCM in preeclamptic patients and timely initiation of bromocriptine with standard therapy can improve cardiac recovery. Multidisciplinary management is key to addressing treatment hesitancy and improving maternal outcomes in Indian settings.