In Reply

The correspondence from our colleagues Pfeffer, Berliner, and Bauersachs is an important addition to our article (1). Indeed, we did not elaborate on the importance of cardiac disease in puerperium, or on peripartum cardiomyopathy (PPCM) in particular, except for a brief mention in the Introduction. The incidence of (pre-existing) cardiac diseases in pregnancy and in puerperium is increasing, and these diseases are important causes of maternal morbidity and mortality. We did not go into the importance of pre-existing cardiac conditions, as they represent a complex entity in their own right that was not possible to describe in the scope of our CME article. However, we agree with our colleagues that PPCM, as a serious and life-threatening disease specific to pregnancy and the puerperium period, should be included in an article on puerperium disorders.

We can confirm the information provided by our colleagues regarding the incidence, symptoms, diagnosis, course, and therapy of PPCM. In addition, we would just like to mention that the international incidence shows large variations (which also depends on ethnicity). A 2019 review of the global importance of PPCM reports the highest incidence rates in Nigeria (1 : 102 births) and the lowest in Japan (1 : 15 533 births); in European countries, the highest is in Sweden (1 : 5900 births) and the lowest, in Denmark (1 : 10 000 births) (2). As described in the correspondence, the incidence in Germany is between 1 : 1000 and 1 : 1500 births.

Important risk factors are hypertensive disorders of pregnancy (and especially preeclampsia and hemolysis) and the hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, as well as advanced maternal age, multiple pregnancies, multiparity, and African (as compared to Caucasian or Asian) ethnicity.