///2010 Abstract Details
2010 Abstract Details2018-05-01T17:52:49+00:00

Contractions? "Yes. Never mind, I cant breathe." PPCM or AFE?

Abstract Number: 158
Abstract Type: Case Report/Case Series

Ramola Bhambhani M.D1 ; Lale Odekon M.D, PhD2

Introduction: Cardiac arrest during pregnancy is a rare event (1/30,000) pregnancies1. Overall, 75% of CPR attempts are unsuccessful2. The outcome of CPR depends on the cause of arrest and the quality of CPR. Resuscitative efforts should take into account both mother and the fetus. Aortic dissection, pulmonary embolism (PE), amniotic fluid embolism (AFE) and trauma are frequent causes of maternal code. We are presenting a maternal code due to previously undiagnosed peripartum cardiomyopathy (PPCM).

Report: A 37-year-old G1P0 obese Hispanic female at 40 weeks gestation with h/o GDM (no h/o pre-eclampsia/eclampsia) presented to the L&D with severe respiratory distress and undetectable FHT/FHM. She had dinner, had SROM, became SOB and was brought to the ER. She was tachypneic, cyanotic, clenching her teeth, frothing at the mouth, and had a spO2 of 76% on NRB. Peripheral pulses were palpable and EKG showed ST of 155. She had bilateral lung crackles. Initially alert and responsive, she became combative. Attempts to assist ventilation were unsuccessful. IV access was obtained and LUD was applied. RSI was done with etomidate and succinylcholine, white foamy secretions suctioned at the glottis, airway secured and confirmed. HR decreased to 60 and then to a non-perfusing rhythm despite atropine. ACLS started (epinephrine, vasopressin and volume resuscitation). Four minutes into the code, the infant was delivered by C/S(handed to the NICU team). The mother regained her pulse; CPR was concluded. Patient was transported to the OR for closure of abdominal incision and then to CICU. Serial ECHOs showed global HK, chamber dilatation and initial LVEF of 15%. Spiral CT was negative for PE. A diagnosis of PPCM was made. On POD#0 she was awake, neurologically intact, and was extubated, but within 2 hours went into flash pulmonary edema which responded to treatment. Discharged home on POD#10 with EF of 40% (on lisinopril, furosemide, metoprolol) and full neurological recovery. Baby discharged after NICU care.

Discussion: D/D excluded aspiration (awake and alert initially, no particulate matter seen and rapid improvement with treatment). Spiral CT of the chest was negative for PE. Her presentation is consistent with PPCM (heart failure in the last month of pregnancy without any previous history of cardiac disease, EF<45%3). AFE is also possible secondary to the contiguity of SROM and SOB, however she never developed DIC. Although D/D is important in this case, it is also imperative to be cognizant of modifications to ACLS during pregnancy (LUD, emergency C/S within 5 minutes of CA, and giving all ACLS medications irrespective of their potential effects on the fetus4) to ensure an optimal outcome.

References:

1. Obstet Gynecol Clin North Am. 2007 Sep; 34(3):585-97, xiii

2. Clin Obstet Gynecol. 2002 Jun;45(2):377-92.

3. Int J Cardiol. 2007 Jun 12; 118(3):295-303.

4. Circulation. Issue: Volume 112(24) Supplement, 13 December 2005, pp IV-150-IV-153

SOAP 2010