Case Presentation

Dr Namkha DorjiResident (Phase B)Department of Obstetrics & GynaecologyBangabandhu Sheikh Mujib Medical UniversityDhaka, BangladeshCase Presentation 10/29/20151Dr Namkha Dorji,Resident, OBGYN, BSMMU

Patients particulars:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU2Name: Mrs Sumoti RaniAge: 35 year Address: SunamganjBed: FM 17Ward: 8AUnit: RedDoA: 14th October, 2015History on: 14th October, 2015

Presenting complaints:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU3Pregnancy for 37+6 weeks

History of heart disease and hypertension for 10 years

History of presenting complaints:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU4Diagnosed heart disease and hypertension- 10 yearsPlanned pregnancy No preconceptional counselling LMP: 22/01/2015EDD: 29/10/2015Regular ANC visitUneventful T1 & T2: normal routine investigations.T3: one episode of breathing difficulties : managed conservatively

Gravida : 3Para: 2 + 0P1: NVD & P2: LUCSALC; 4 yearsCorresponds with early USG EDD

10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU5

Fetal movement good

Good exercise tolerance

Admitted for confinement

Past obstetrics history:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU6

Second pregnancy (2011)10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU7

Past medical history:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU8

DCM & hypertension (since 2005) on regular follow up asymptomatic on Tab. Angilock (25/100) daily one tab

Past surgical history:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU9Tonsillectomy ( about 20 years back)LUCS under SA ( in 2011)No post operative complications: anesthesia or surgical related.

Drugs history:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU10 In addition to routine vitamins supplement:

Tab. Furosemide 10mg OD Tab. Labetalol 100mg BDTab. Methyl Dopa 250 mg BD

No significant side effects

Family History:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU11

Social History:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU12

TeacherHusband is Government service holderSmoker Good family support

10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU13Examination findings

General examination:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU14

Not dyspneoic Mild pallor No cyanosis No thyroid enlargement or engorged neck vein No ankle oedema PR: 80 b/m, regular rhythm and good volume BP: 140/80 mmHg

Cardiovascular system:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU15

Apex beat: 5th ICS in left midclavicular line.

No added sounds or murmur

Respiratory system:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU16

Equal Air entryVesicular breath soundNo crepitation in the bilateral lung bases

Obstetric examination:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU17Well healed previous pfannenstiel scarFundal height: 36 weeksLongitudinal lieLeft occipito anterior positionCephalic presentationHead not engagedLiquour: adequateEFW: 3000 gramsFHS: 148 bpmNo scar tenderness

10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU18

P/V/E

NOT DONE

Clinical Diagnosis:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU19

Third gravida at 37+6 weeks pregnancy with peripartumcardiomyopathy( NYHA grade I) and chronic essential hypertension with history of previous one LUCS

Discussion period:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU20

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Summary:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU22Mrs Sumoti Rani, 35 year, from Sunamganj, mother of two children(P1:NVD & P2:LUCS) in her third pregnancy is admitted at 37+6 week. She is a diagnosed patient with peripatum cardiomyopathy and chronic essential hypertension for last 10 years on drugs. Her exercise tolerance is good and she is not in labour. Her two sisters as well has perpartum cardiomyopathy.Other than mild anemia, there is no significant findings on general, Respiratory system and cardivascular examination. On obstetric exam, fundal height corresponds to 36 weeks with cephalic presenation and longitudinal lie. Liquour is adequate and FHS present. There is no scar tenderness.

Outdoor management:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU23

In ward care:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU24Multidisciplinary team approach

ObstetricianCardiologist Anesthesiologist Neonatologist??? Husband & her relatives

Plans on admission:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU25

Management:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU26Counselling Cardiology opinionAnesthesia opinion ICU/NICU/CCUAntibiotic prophylaxisEpidural anesthesia/analgesia + systemic angesicsControlled I/V fluid administrationBLTL doneVery close monitoring

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10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU29

10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU30

10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU31

10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU32

PPCM10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU33

Incidence: 1:300 to 1:4000 pregnanciesPostpartum cardiomyopathy or puerperal heart failurePeripartum cardiomyopathy: symptoms & signs of this disease may appear at any time in the last month of pregancy and up to 5 months after delivery.

Risk Factors:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU34

Advanced maternal ageMultiparityMultifetal gestationObesityBlack race

Criteria for diagnosis:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU35

Development of heart failure in the last month of pregnancy or up to 5 months postpartumAbsence of an identifiable cause for heart failureNo recognisable heart disease before the last month of pregnancyLeft ventricular systolic dysfunction shown by echocardiographic criteria.

Symptoms:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU36

WeaknessShortness of breathOrthopnoeaCoughParoxysmal nocturnal dyspnoepalpitations

Signs:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU37

TachycardiaCardiac arrhythmiasPulmonary crepitationsPeripheral oedema

Investigations:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU38

CXR: enlarged heart & pulmonary vascular distributionEcho & right heart catheterization: enlargement of all chambers of the heart, predominantly left ventricle. LV EF & CO are decreased & pulmonary wedge pressure is increased.Thrombosis & PE

Management:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU39

Bed restDigitalisDiureticsAnticoagulantsImmunosuppressant therapy- not recommended

Prognosis:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU40

High mortality- dilated heart 6 months after the initiation of therapyGood prognosis- normal sized heart 6 months after the initiation of therapyPoor- treatment initiated 6 months after the onset of symptoms

Recurrence:10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU41

21 % in women whose LV function returned to normal44 % in persistent LV dysfunction