Peripartum cardiomyopathy: A comparative analysis of twin versus singleton gestational risks: A narrative review

Background. Peripartum cardiomyopathy is an idiopathic left ventricular systolic heart-failure syndrome presenting in late pregnancy or up to five months postpartum, with global incidence ranging from 1 per 1000–4000 births in North America and Europe to 1 per 100–300 in parts of sub-Saharan Africa. Multifetal gestation is a recurring risk factor, though its adjusted magnitude is uncertain. Aim. To synthesise contemporary evidence on whether multifetal gestation constitutes an independent, mechanistically grounded PPCM risk factor. Methods. A structured narrative review (January 2000–March 2026) of PubMed/MEDLINE, Scopus, and Web of Science records, supplemented by reference-list and guideline cross-referencing, including peer-reviewed primary studies, systematic or narrative reviews, and meta-analyses on PPCM epidemiology, hemodynamics, molecular biology, therapy, and prognosis in multifetal versus singleton gestations. Results. A 2024 Finnish record-linkage study identified twin pregnancy as conferring an adjusted odds ratio of 2.74 (95% CI 1.37–5.49, p = 0.005) for peripartum heart failure, comparable to pre-eclampsia (aOR 2.43) (Puhakka et al., 2024). Twin gestation imposes 20% greater cardiac output, 15% greater stroke volume, and 13.5% greater left ventricular mass than singleton pregnancy, with progressive third-trimester loss of long-axis systolic efficiency (Kametas, 2003). A 2025 systematic review confirmed multifetal gestation as a recurrent risk factor across diverse cohorts (Dewi et al., 2025), corroborated by a 2022 global meta-analysis of over 7,000 cases from 41 studies (Hoevelmann et al., 2022). Conclusions. Multifetal gestation is an independent PPCM risk factor of comparable magnitude to pre-eclampsia, mediated by hemodynamic loading and amplified anti-angiogenic signalling on a genetic substrate (Davis et al., 2020). Incorporation of pregnancy plurality into stratified PPCM risk models is justified by this synthesis (Jackson et al., 2023).