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MANAGEMENT OF A PARTURIENT WITH ACUTE RESPIRATORY FAILURE RESULTING FROM PERIPARTUM CARDIOMYOPATHY
Abstract Number: T4D-1
Abstract Type: Case Report/Case Series
INTRODUCTION: Peripartum cardiomyopathy (PPCM) is potentially life-threatening with left ventricular dysfunction and heart failure. Most PPCM occur at the time of delivery or within the first weeks after delivery. Catastrophic presentation can occur with severe respiratory failure and low-output cardiac failure requiring mechanical ventilation and pharmacological support.
CASE: A 25 years old G2P1 at 37 weeks presented for labor with hypertensive urgency. Her medical history is significant for chronic hypertension (LVEF 55% at 25 weeks) and hyperthyroidism (currently normal thyroid function). Patient was diagnosed with severe preeclampsia at admission by blood pressure of 180s/100s, proteinuria, and elevated liver enzymes. She was given hydralazine and on magnesium infusion. Urgent cesarean section (C/S)proceeded due to severe preeclampsia and breech presentation. Spinal anesthesia applied to achieve surgical level and the patient was hemodynamically stable. Soon after delivery she became hypotensive (80s/30s) and oligouria despite of challenges of fluid and pressers (ephedrine, phenylephrine). Blood (2u) was then given which improved blood pressure and urine output. Six hours later in recovery, she presented with signs of pulmonary edema (evident on CXR) and respiratory distress (rate of 30's, O2 saturation of 85% on 15L). Furosemide boluses resulting appropriate diuresis which improved her symptoms. However with intermittent hypoxic episodes, patient was admitted to ICU where she was intubated due to fulminant pulmonary edema. Initially, she was hypotensive and was put on dopamine and norepinephrine infusions for a short period. TTE showed concentric LV dilation and global hypokinesis of the left ventricle with LVEF 35% (with inotropic infusions) which confirmed our diagnose of heart failure. Her medical management in ICU included furosemide, hydralazine, Labetalol, and slow weaning from ventilator. Patient responded the therapy extremely well and was discharged from ICU on day five after repeated ECHO showed LVEF 61% with normal wall motion. She was discharged home three days later.
DISCUSSION: Peripartum cardiomyopathy (PPCM) is defined by development of heart failure (LVEF<45% )in the past month of pregnancy or within five months of delivery and there is no previous known structure heart disease (1). The cause of PPCM remains unknown, but preeclampsia and hypertension have shown strongly predispose to PPCM(2). Preeclampsia can cause cardiac diastolic dysfunction and in some cases can co-exist with PPCM (LV systolic dysfunction). Preeclampsia can cause pulmonary edema due to capillary leak and in most cases with reserved cardiac function. Management of PPCM is focused on systolic failure: In addition to volume control and diuresis, hydralazine and beta blockers are preferred agents (3).
1.Sliwa et al. Eur J Heart Fail 2010;12:767-778
2.Bello et al. J Am Coll Cardiol 2013;62:1715-1723
3.Desplantie et al. Can J Cardiol 2015;31:1421-1426