June 21, 2012Balderama-Mendieta

OBJECTIVES Identify pertinent findings from the history and

physical examination that would contribute to the diagnosis of peripartum cardiomyopathy

Provide a systematic approach in diagnosing patients with peripartum cardiomyopathyDetermine supportive diagnostic examinationsArrive at a definitive diagnosis

Learn how to conservatively manage patients with peripartum cardiomyopathy

Patient Profile

32 year-old , Female Single, Filipino, Roman

Catholic From Quezon City Admitted for the 1sttime at our

institution on November 30, 2011

Patient Profile

 Merchandiser Drinks 2 liters of fluid per day, rarely

drinks coffee Doesn’t drink alcoholic beverages Denies smoking and taking illicit

drugs

Patient Profile

Rents the 1st floor of a 4-storey studio type apartment

Sufficient source of water and electricity in the neighbourhood

Garbage collected twice a week

Chief Complaint

Difficulty of breathing of few hours

Source and Reliability The patient herself with fair

reliability

Past Medical History Anterior Neck Mass, T/C Nodular Non-

toxic Goiter, Biochemically and Clinically Euthyroid – November 2, 2011

Maternal History

Menstrual History Menarche at 16 y/o, regular, 28-day cycle,

3 days duration, moderately soaked, 3 pads per day, no dysmenorrhea

Obstetrical History: G2P1 (1011) G1- 2004, Spontaneous abortion G2- 2011, LFT male via NSD, delivered at

a lying-in-clinic by a mid-wife

Gynecologic History History of pelvic infection, UTI at 16 3/7

weeks AOG of G2 (treated with Cefuroxime 500 mg/tab BID, resolved)

Sexual History Coitarche at 23 y/o, 2 SP, no post coital

bleeding or dyspareunia  Contraceptives History

None

Family History

Hypertension, CVD, and asthma – paternal and maternal sides

Review of SystemsGeneral (-) significant weight loss, (+) weight gain

Skin (-) lumps, (-) sores, (-) itching, (-) changes in color; (-) changes in hair or nails, (-) changes in size or color of moles,

Head (-) headache, (-) head injury, (-) dizziness and (-) light-headedness

Eyes (-) icteric sclerae, (-) pale palpebral conjunctivae

Ears Unremarkable

Nose (-) frequent colds,(-) discharge, (-) itching, (-) nosebleed

Throat (-) dentures, (-) hoarseness,(-) dry mouth, (-) frequent sore throats

Neck (-) swollen glands, (+) anterior neck mass, (-) lumps, (-) pain and stiffness

Review of Systems

Cardiovascular (-) dyspnea, (-) easy fatigability, (-) orthopnea, (-) palpitations

Gastrointestinal (-) dysphagia, (-) nausea and vomiting, (-) melena, (-) jaundice, (-) indigestion, (-) fatty food intolerance, (-) acholic stool, (-) changes in bowel movement

Urinary (-) polyuria, (-) nocturia; (-) hematuria, (-) retention, (-) bleeding

Genitoreproductive (+) gravidumstriae, (+) lineanigra, (+) gravid uterus

Musculoskeletal (+) swelling both feet, (-) redness, (-) no history of trauma

Respiratory (-) cough, (-) hemoptysis, (-) dyspnea, (-) wheezing, (-) tuberculosis

Review of Systems

Psychiatric (-) nervousness, (-) tension, (-) mood changes, (-) depression, (-) memory change

Neurologic UnremarkableHematologic (-) anemia, (-) easy bruising or bleedingEndocrine (-) excessive sweating, (-) excessive

thirst or hunger

PHYSICAL EXAMINATION

Admitting Physical Examination

General Survey

Awake, alert, ambulatory, weak-looking, ectomorph, in cardiorespiratory distress

Vital Signs

BP 130/90; HR 109bpm; RR 25bpm; 36.1C

Admitting Physical Examination

Anthropometrics Height: 157 cm Weight: 48 kg BMI: 19.5

HEENT Anicteric sclerae, pink palpebral conjunctivae, no tonsillopharyngeal congestion, no cervical lymphadenopathies, distended neck veins

Admitting Physical Examination

Chest/Lungs Equal chest expansion, with subcostal retractions, dullness noted on both lower lung fields, decrease vocal fremitus on both lateral fields, decrease breath sounds on both lower lung field, noted with bibasal crackles

Admitting Physical Examination

Heart Adynamic precordium, tachycardic, regular rhythm, distinct S1 and S2, PMI at 5th ICS, MCL, no murmurs

Abdomen Globular, soft abdomen, NABS, no tenderness, no palpable masses

Admitting Physical Examination

Extremities Grade 3/5 pulses on all extremities, Grade 2 bipedal edema, cold extremities, no cyanosis

MSE Intact

Cranial Nerves

Intact

SALIENT FEATURES

Salient Features

Salient Features

ADMITTINGIMPRESSION

CONGESTIVE HEART FAILURE vs. PERIPARTUM CARDIOMYOPATHY.

Complete Blood Count (11.30.11)11.30.11 12.03.11

Hemoglobin 181 g/L 151 g/LHematocrit 52% 45%RBC 5.7 x 1012/L 4.8 x 1012/LWBC 15.4x109/L 8.1x109/LNeutrophils 85% 56%

Lymphocytes 14% 36%Monocytes 4%

Eosinophils 3%

Basophils 1%

Platelets 442 x 109/L NormalRemarks Normochromic,

normocyticNormochromic, normocytic

Urinalysis (11.30.11)Color Light yellow

Turbidity Slight cloudy

Reaction Acidic

S. Gravity 1.015

Protein (++)

Sugar Negative RBC 20-25/hpfWBC 0-2/hpfCast NoneBacteria FewEpithelial Cells FewCrystals None

Mucous Threads None

Yeast Cells None

Arterial Blood Gas (11.30.11)

pH 7.45

pCO2 32 mmHg

pO2 60 mmHg

HCO3 22.20 meq/L

Base Excess (ECF) -1.80

O2 Saturation 92%

Total CO2 23.20

Salient Features

Salient Features

Imp: PERIPARTUM CARDIOMYOPATHY

Peripartum cardiomyopathy is diagnosed using four criteria based on the work of Demakis et al 1971. Development of cardiac failure in the last month of

pregnancy or within 5 months of delivery Absence of an identifiable cause for the cardiac failure Absence of recognizable heart disease prior to the last

month of pregnancy  Additional echocardiographic measures were included

with the benefit of echocardiographic findings:○ Left ventricular systolic dysfunction described as ejection

fraction of less than 45%, fractional shortening of less than 30% or both, and end diastolic dimension of greater than 2.7cm/m2 body surface area.

Hypotheses of PPCM

Myocarditis Abnormal Immune Response to Pregnancy Response to Hemodynamic Stresses of

Pregnancy Other causes:

Prolonged tocolysisStress-activated Proinflammatory

cytokines such as TNF a or IL-1Abnormalities of relaxinDeficiency of Selenium

Management Treatment is essentially the same with

dilated cardiomyopathy Goals:1. To reduce to amount of volume returning

to the heart (preload reduction)2. To decrease the resistance against which

the heart must pump (afterload reduction)

3. To increase the contractile force of the heart (inotropy).

Preload and afterload reductionLoop diuretics (caution in women with

preeclampsia)Hydralazine, nitrates and beta blockers

InotropyDigoxin (unless contraindicated)Dobutamine, dopamine, milrinone

Prophylaxis for thromboembolismLow dose heparin

Immunosuppressive therapy may be needed if peripartum cardiomyopathy is considered to be the result of myocarditis.

Patients should have a low sodium diet (≤ 4 gm) and fluid restriction (≤2L).

Activity should only be limited depending on the patient’s symptoms.

Cardiac transplantation and left ventricular assist devices are considered for women with progressive left ventricular dysfunction or deterioration despite medical therapy, however since most patients improve over time, surgical therapy should be delayed if possible.

Suggested Treatment Plan1. Institute ACE inhibitor therapy with

enalapril 5 mg twice daily and titrate up to a maximum dose of 20 mg twice daily, yet maintain SBP to 100 -110 mm Hg.

2. Start digoxin to achieve a serum level of 1 to 2 ng/dl.

3. Start diuretic therapy (furosemide 20 to 40 mg once daily) to control symptoms related to volume excess.

*Peripartum cardiomyopathy: A comprehensive reviewAmerican Journal of Obstetrics and Gynecology - Volume 178, Issue 2 (February 1998)

4. Start low-dose beta-blocker therapy (i.e., metoprolol 12.5 mg twice daily) and titrate for heart rate 80 to 100 beats/min.

5. Add additional vasodilator agents as needed to control systemic blood pressure (e.g., goal is systolic blood pressure  110 mm Hg).

6. Monitor ambulation for 24 to 48 hours.

7. Dietary consultation for fluid-restricted, low-salt diet.

8. Detailed patient education and counseling.

9. Referral to exercise rehabilitation program.

10. Vigilant follow-up to include measure of cardiac function within 3 to 6 months of treatment onset.

Prognosis Prognosis depends on return to normal left

ventricular function after the first episode of CHF.

In a study by Damaskis et al, they have observed that if the congestive cardiomyopathy persists after 6 months, it is likely irreversible and associated with a worse survival.

Recent studies have found that 30% of patients return to their baseline function after 6 months if given timely medical treatment.

Prognosis Mortality rate is 10% and the usual

causes of death include progressive heart failure, arrhythmia, or thromboembolism.

Patients who have peripartum cardiomyopathy are advised to avoid subsequent pregnancies due to concerns about the hearts inability to handle the increased cardiovascular workload during pregnancy.

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