Rajshree Dayanand Katke, Ashish Zarariya
From
the Department of Obstetrics & Gynaecology, Grant Government
Medical College & Sir J. J. Group of Hospitals, Mumbai, Maharashtra,
India.
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Introduction:
Peripartum
cardiomyopathy is defined as onset of heart failure in the last month
of pregnancy and first 5 months post-partum with no other etiology of
heart failure identified and no history of cardiac disease. The
dysfunction is characterised by a reduced ejection fraction. High risk
factors include black race, advanced maternal age, multiparity, multiple
gestation, pre-eclampsia and stress [1,2].
Symptoms include fatigue, edema, dyspnea which may lead to false
diagnosis of other pregnancy co-morbidities such as pulmonary embolism
and eclampsia [3].
The following case report illustrates a typical presentation of
peripartum cardiomyopathy in a patient with triplet pregnancy with
complete recovery after treatment.
Case Report
A
30 year old primigravida, married since 10 years, infertility
conception, booked case at private hospital, 32 weeks by dates and by
scan, with triplet gestation was admitted for safe confinement at our
institute. Patient was mildly anaemic with no other risk factors. She
was treated with oral hematinics and steroids. Routine ultrasound
doppler study at 34 weeks was suggestive of first fetus in breech
presentation with feto-placental insufficiency. Planned caesarean
section was performed at 34 weeks under spinal anaesthesia. There were
no intra or immediate post-partum complication to mother and fetus. Baby
weights were 1.6 kg, 1.7 kg and 1.7 kg. One unit blood transfusion was
given post-operatively in view of pre-operative haemoglobin 8.2 gm/dL.
Sixteen hours after operation, patient complained of breathlessness and
cough. Examination revealed bilateral crepitations on auscultation.
Oxygen saturation was 84%. On further investigation chest X ray
revealed cardiomegaly [Fig.1]. Electrocardiogram was within normal
limits and echocardiogram revealed cardiomegaly with LVEF of 35% with
grade 1 mitral regurgitation. Patient was treated with oxygen by nasal
prongs, injection furosemide, tablet enalapril 2.5 mg, tablet carvedelol
3.125 mg and tablet aldactone 50 mg. On post operative day 5 patient
was stable and maintaining saturation of 98% without oxygen. Patient was
discharged on 24th postoperative day in healthy condition with healthy
babies with a advice for barrier contraception and follow up 2-D Echo
after 3-6 months.
Discussion:
Peripartum
cardiomyopathy is often missed because dyspnea in a common finding
during pregnancy and post-partum period and is the earliest symptom of
peripartum cardiomyopathy. If pregnant women gain excessive amounts of
weight, have significant lower-extremity edema, or have jugular venous
distension in the presence of gallop rhythms or cardiomegaly then they
should be referred for an echocardiogram. Normal pregnancy is associated
with an increased heart rate and left ventricular diastolic function;
there should not, however, be elevations in diastolic dimensions beyond
normal levels or reductions in ventricular function during gestation or
the postpartum period.
Women
with suspected peripartum cardiomyopathy must undergo a careful medical
and family history assessment and investigations to exclude
pre-existing heart disease or intercurrent causes of left ventricular
compromise. Chest radiography can reveal cardiomegaly, pulmonary
congestion and sometimes pleural effusion [4].
Electrocardiogram findings are often normal hence an echocardiogram
should be done to document ventricular size. In our case, the chest
X-ray revealed cardiomegaly, electrocardiogram findings were normal but
echocardiogram revealed cardiomegaly with LVEF of 35%. Treatment
includes fluid restriction, use of diuretics, beta blockers and digoxin.
Such patients are at high risk for thrombus formation [5].
Thus anticoagulation should be considered in patients with severe LV
dysfunction. Irrespective of recovery further pregnancy should be
avoided since it recurs in 30% of pregnancies [6].
Thus it is important to consider peripartum cardiomyopathy, when
diagnosing dyspneic patients for faster initiation of treatment for a
potentially lethal condition. Following discharge patients are seen at
2-week intervals. The echocardiogram should be repeated at these visits
until ventricular function improves [7].
Once stable, the outpatient visit and echocardiogram interval is
determined by the patient’s clinical state. With proper medication, diet
and exercise, ventricular remodelling is usually complete within 6
months of initial presentation.
Conclusion:
Diagnosing
peripartum cardiomyopathy is a challenge to the physicians. Our case is
a unique example where two high risk conditions of triplet pregnancy
and peripartum cardiomyopathy were managed with successful outcomes by
multidisciplinary approach in obstetric setup. Prompt diagnosis and
treatment of peripartum cardiomyopathy had helped the mother to fight
this lethal condition.
References:
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Monday, 10 November 2014
Successful Outcome of Triplet Pregnancy with Peripartum Cardiomyopathy
Wednesday, 5 November 2014
Saturday, 1 November 2014
Rupture and torsion of a huge ovarian cyst with ipsilateral para-ovarian cyst presented as haemoperitoneum and acute abdomen: A rare case report and review of literature
www.ijrhs.com
ISSN (o):2321–7251
By,
Dr. Rajshree Katke
Pdf Link for detailed Content:
https://drive.google.com/file/d/0B7e9SrenxWTaQ0V0OGhpdzBHZTVwUTJMV3c1ckV0VjBIdUFF/view?usp=sharing
ISSN (o):2321–7251
By,
Dr. Rajshree Katke
Pdf Link for detailed Content:
https://drive.google.com/file/d/0B7e9SrenxWTaQ0V0OGhpdzBHZTVwUTJMV3c1ckV0VjBIdUFF/view?usp=sharing
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