PERIPARTUMCARDIOMYOPATHY

Dr.Maya MenonAsst.Prof SRM Medical College

Prof.Shantamani

CASE REPORT

Mrs.S aged 26,P1L1 referred from Chengalpet Medical College on 4/10/11 at 7:30am,post LSCS.

H/o high-grade fever,breathlessness, abdominal distension & purulent discharge from the LSCS wound.

LSCS done on 2/10/11 at 6:30am at Chengalpet Medical College-Ind-PROM with failed induction.

Past History-no H/o cardiovascular disease.

ON EXAMINATION…….

Patient is toxic & breathless.

No pallor,bil pedal oedema+

Temp-103 deg F,PR-110/min,BP-150/90, RR-40/min,CVS-S1S2 heard, RS-bil basal creps & bil rhonchi.

P/A-Abd distension+,bowel sounds sluggish with purulent discharge from the wound.

L/E-lochia unhealthy.

INVESTIGATION

Hb-10.4%,TC-14,900cells,Plat-80,000cells/cumm.Bld-urea-52mg,S creat-1mg,RBS-90 mg, Na-143,Ca-0.96,K-4.6.PT-15 sec,APTT-32 sec,FDP-10gm/ml,D-Dimer-4.12, Trop T-Neg,CPK &CPKMB-Normal. ABG –Ph-7.214,Pco2-54.8,ECG-normal.

ECHO-Severe Global Hypokinesia of LV chamber dilated, mod-severe LV dysfunction.EF-38%,MR(mod),TR(mild),PHT(mild), no pericardial effusion, no thrombus in LV.Pus, blood & vaginal swab culture & sensitivity-Staphylococcus aureus.

Diagnosis-Peripartum Cardiomyopathy – mod-severe LV dysfunction & Sepsis.Treatment given on 4/10/11 Non invasive ventilation with 40% (FiO2) SpO2-100%Inj Piptaz-4.5g iv 8 hrlyInj Flagyl 8 hrlyDuolin Nebulisation 2 hrly Inj Lasix 40 mg iv bdTab Envas 2.5 mg -1-0-0Tab Digoxin 0.25mg 1-0-0Neg fluid BalanceSerum Electroyte/K+correction.

ON 5/10/11Symptomatically better with Non-Invasive VentilationFever spikes coming downPR- 54/min, BP- 140/90, CVS-S1,S2 heard. RS –No Added sounds.ABG-Alkalosis + Resp Acidosis.Platelets,APTT,PT- Inc.Chest X-Ray =Cardiomegaly.Echo-Global Hypokinesia,Regional variation. IVS/Antwall/Ant Latwall-Severe Hypokinesia 52/43/36%LA-36 mm,AO-30 mm,MR(mod),TR(mild).No pericard Effusion.

ON 6/10/11

Pt symptomatically better.Pt- AfebrilePR-60/Min,BP-130/8OmmHgCVS-S1S2,RS-NormalAbd girth-89cms.Inj Ofloxacin-200mg bdInj Clindamycin-300mg qidTabEnvas2.5mg od ,Aldactone25mg od, Lasix20mg bd,Duolin neb & Allupent 10mg tds ,Atorvas 10mg hs.

ON 7/10/11

Pt symptomatically improved & drugs were continued Cardiologist –ECHO11/10/11. Global hypokinetic contraction of left ventricle,Adequate Left Ventricular Systolic function,LEF-53%,Trivial MR, No PHT,No left atrial /left ventricular clot.Adv-stop Allupent,Lasix,Aldactone;Digoxin.SR done wound gapping with slough +,Resuturing was done on 15/10/11.Pt discharged on 23/10/11 Tab Envas 2.5 mg od ;Tab Fruselac 1/2od & SR diet.

Review on 15/11/11

Pt is fineECHO- Normal LV function.

LVEF – 61%.Adv-tab Envas 2.5mg od & contraceptive counselling given.

DISCUSSION

PPCM is a life threatening form of cardiac failure that occurs in healthy women in the last trimester of pregnancy or upto 5 months after delivery.Incidence-1:4000-15000 live births(US statistics)

1:1000 live births in South Africa1:1374 live births in India1: 300-400 live births in Haiti, Nigeria

Etiology-inflammation,viral infection & auto immunity.Risk factors- advanced age,multiparity,black race, obesity,malnutrition,Gest-HTN, Pre-eclampsia, low Socio Economic,family history,Alcohol , Cocaine,Tobacco Abuse.

Td.rsm journals .com/content/39/3/108.full by V.Pandit 2009. KMC Manipal.

CLINICAL PRESENTATION

Symptoms- Dyspnoea on exertion ,cough, orthopnea & PND.Cardiac thrombus-chest pain,haemoptysis & hemiplegia.Palpitation,fatigue,malaise & Abd pain.Signs- BP is normal –low-elevated.Tachycardia,gallop rhythm,engorged veins & pedal oedema.MR/TR with Pulm crepts & hepatomegaly

INVESTIGATIONS

ECG- Sinus tachycardia,atrial flutter/fibrillation,LVH,non-specific ST-T abnormalities,Left axis deviation,arrhythmia,Q wave in anteroseptal leads & conduction abnormalities.ECHO-Ejection fraction<45%Left ventricular fractional shortening<30%(LVFS)Left ventricular end diastolic dimension>2.7cm/m2 body surface area.(LVEDD)Dilatation of all cardiac chambersMR,AR,PR, Pericardial effusion,Pul Hypertension.

e medicine. Medscape.com/article/153153 overview

CONT….

MRI-Diagnosing thrombi in cardiac chambers.Endomyocardial biopsy -sensitivity-50%,specificity-99%. Contrast MRI guided EMB – good. Pt not improving after 2wks of treatment, pt to undergo cardiac transplant.Cardiac catheterisation -IHD, Acute Coronary syndrome.Cardiac enzymes -N & Coronary angio- N.Biochemical,Haemotological & Serological

Elevated CRP & Cytokines.

PPCM IDCM

Incidence:1:4000 - 15000 live birthsYounger age – better prognosis.Occurs in post partum ( 78 – 93% ).Affects pregnant woman.Various haemodynamic patterns seen. Autoimmune, inflammation. Heart size returns to normalBetter prognosis.Recurrence seen.

Incidence: 36.5/100000 population.Age: older ageOccurs in 2nd trimester.

Affects women with CAD.Haemodynamic pattern deteriorates Familial.Heart size remains sameBad prognosis.

COMPLICATIONS

Obst &Perinatal-Abortion(4-25%),Premature delivery(11-50%),IUGR & Fetal death.Thromboembolism-Hemiplegia, AMI, Pulm embolism, TIA, Infarction of kidney, Splenic infarction.Arrhythmias.Organ failure.

MANAGEMENT

Salt & fluid intake -2-4gm/day,2lt/day.Digoxin.Diuretics.Vasodilators -ACEI or ARB(avoid in preg &lactationg mother), Hydralazine.Ca channel blockers Amlodipine, Levosimendan (Ca sensitizer have vasodilator, improve cardiac contractility)Beta blockers with ACEI -suppress immune response & ↓ ventricular dimensions.

Anticoagulant –LEVF<35%& bedridden pts.Immunosuppressive therapy -Azathioprine & prednisolone.I.V Immunoglobulin Immunomodulation-Pentoxifylline-↓TNF,CRP&Fas/apo-1.Surgical-Cardiac transplants.

Journal of American college of cardiology Biykem Bozkurt 1999

OBSTETRICS MANAGEMENT

Induction of Labour with regional analgesia to reduce cardiac stress of labour pain.LSCS- Fetal cause.ICU care mustFuture preg-ContraIndicated & IUCD/Barrier contraception/Permanent sterilisation advised.

ANAESTHETSIA

Spinal Anaesthesia- ContraIndicated (Cardiac arrest &Pul oedema).

Controlled Epidural Analgesia.

Combined spinal epidural analgesia.

Post op-Strict intake/output chart.

Anticoagulants.www.joacc.com/text 2011/1/1/5/84249 ramachandran 2011

Recovery from PPCMLEVF>50%,LVFS>30%.

Recovery occurs in 2 months it can take 6-12 months.

5 years survival rate is 94% with complete recovery of ventricular function.

Erin martineau Aug 7 2008

POOR PROGNOSIS CRITERIA

Higher ageParityMultiple gestationIntracardiac thrombiPersistence of LV dysfunction 6 months after RxDelay in starting medical RxHigher LVEDD (>5.6cm),PAP & PCWP & reduced LVFS & LVSWI.Mortality-50%.Risk of rec- Lamper et al - recurrence of PPCM was seen in pts whose ventricular size & function returned to normal.

Erin martineau Aug 7 2008

FUTURE RESEARCH

Research to find actual etiopathology with emphasis on inflammation, viral, auto immuneTherapeutic role of immunoglobulin, pentoxyfylline & levosimendanshould be evaluated by larger trials.Caspase inhibition used in mice to improve ventricular function should be tried in PPCM.

Pre conceptional counselling

Women should undergo ECHO & if findings are normal dobutamine stress ECHO Pregnancy is not recommended to women with persistent left ventricular dysfunctionPatients with normal findings in ECHO but decreased contractile reserve should be warned that they may not tolerate the increased haemodynamic stress in pregnancyPatients with full recovery – although chances of recurrence exist mortality is low.

N Eng J Med 2001;344:1567-71

CONCLUSION

PPCM is rare but devastating cardiac failure.Diagnosis-ECHO.EMB-resistant case.Medical Rx- Digoxin, Diuretics, Vasodilators, beta blockers, Anticoagulants,Resistant- Immunosuppressive drugs, Immunoglobulin & Pentoxifylline.Severe cases- Cardiac transplant.LSCS-Obstetric indicationRegional Technique is safe for analgesia & anesthesiaPrognosis depends on recovery of ventricular dysfunctionFuture Pregnancy is better avoided.