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gestational hypertension, and African American race (Pearson et al, 2000) It is unclear if racial status is an independent risk factor or a result of an interaction of race and hypertension While the etiology of PPCM remains unknown, current evidence suggests PPCM is a type of myocarditis (in ammation of the muscular tissue of the heart) with proposed causes such as abnormal immune responses to pregnancy, maladaptive responses to the hemodynamic stresses of pregnancy, stress-activated cytokines, and prolonged tocolysis (Pearson, et al, 2000) In some women, PPCM resolves completely after delivery; however, there is a high mortality rate for women who do not experience a resolution of symptoms within six months following delivery (C Brown & Bertolet, 1998), with mortality rates in the United States ranging from 25% to 50% (Lampert & Lang, 1995).

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Women with PPCM appear to be at high risk for pregnancy complications or mortality should they become pregnant again (C Brown & Bertolet, 1998; Lampert & Lang, 1995) Because of the limited understanding of the medical etiology of PPCM, the majority of research has focused on the medical aspects, failing to address psychosocial factors related to PPCM and its impact The sudden and unexpected nature of PPCM compounds the stress for women and their families, who are also adjusting to the physical and emotional demands normally imposed by pregnancy and the birth of a child In one of few studies examining psychosocial factors relating to PPCM, Geller, Striepe, Lewis, and Petrucci (1996) studied a sample of women with PPCM admitted to a heart transplant unit for evaluation Factors such as stressful life events (eg.

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Comparison of the delayed type hypersensitivity (DTH) response to acute stress in animals and humans adds complexity to the domain of acute stress For example, stress associated with an academic examination suppressed DTH responses in subjects who reported higher levels of stress (Vedhara & Nott, 1996), while acute restraint stress in rodents during the sensitization or challenge phase enhanced DTH responses (Dhabhar & McEwen, 1997; Dhabhar, Satoskar, Bluethmann, David, & McEwen, 2000) In another study, socially inhibited individuals showed heightened DTH responses compared to controls following ve weekly sessions of high-intensity social engagement (Cole, Kemeny, Weitzman, Schoen, & Anton, 1999) Further research will be required to understand these complex interactions The clinical importance of the immunological changes associated with examination stress is underscored by several ndings.

In their critical work on psychotherapy, Frank and Frank (1991) further clarified the notion of characterologically anchored belief systems:

, history of abuse or unstable relationships; history of miscarriage or cesarean section), health-related behaviors (eg, substance use; nutritional/dietary concerns), social support, and coping style were assessed (Geller, Striepe, & Petrucci, 1994) In addition to the stressors of pregnancy and the diagnosis of PPCM, these psychosocial factors could potentially exacerbate the physical symptoms or contribute to treatment-related issues, such as noncompliance, comorbid psychological or substance abuse disorders, and adjustment to lifestyle changes imposed by the illness Studies employing appropriate comparison cohorts are needed to further evaluate these psychosocial factors..

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