Peripartum cardiomyopathy: a condition intensivists should be aware of

[Cardiopulmonary emergencies during pregnancy and the postpartum period]

The number of patients who develop cardiac problems during pregnancy are increasing and represent to date the major cause of maternal death in western countries. Pregnancy induces several changes which together increase the hemodynamic burden on the cardiovascular system and can also cause a prothrombotic state. Hence, latent or apparent cardiac disease can acutely decompensate during pregnancy. From a cardiovascular perspective, pregnancies are most often complicated by acute coronary syndromes, peripartum cardiomyopathy, arrhythmias, or pulmonary embolism. Due to potential fetal harm conventional diagnostic and therapeutic approaches are limited by the restricted use of radiogenic cardiac imaging and applicable medications. Therefore, knowledge about available therapeutic options is of greatest importance, since guideline recommendations have clearly been demonstrated to reduce morbidity and mortality in acute cardiac emergencies during pregnancy.

An unusual case of peripartum cardiomyopathy in a parturient with preeclampsia

Here we report an unusual development of peripartum cardiomyopathy (PPCM) in a parturient woman with preeclampsia. A 36-year-old nulliparous parturient woman underwent elective cesarean section for delivery of twins under spinal anesthesia. Both preoperative workup and past history were unremarkable except for proteinuria and hypertension for 1 week. Approximately 4 hours after cesarean section, progressive orthopnea developed. Chest plain film showed acute pulmonary edema, bilateral pulmonary infiltration with interstitial patches, and cardiomegaly. Postpartum cardiomyopathy was diagnosed afterward by echocardiography. This showed general hypokinesia and severe dysfunction of the left ventricle with ejection fraction of 15-20%. She was admitted to the intensive care unit for further management. Fortunately, the patient recovered after treatment and was discharged 15 days later. This case illustrates that we should bear in mind the possibility of PPCM if orthopnea develops while delivery is approaching in a parturient with preeclampsia. Echocardiography is helpful for early diagnosis of PPCM.

Obstetric intensive care unit admission: a 2-year nationwide population-based cohort study

PURPOSE

As part of a larger nationwide enquiry into severe maternal morbidity, our aim was to assess the incidence and possible risk factors of obstetric intensive care unit (ICU) admission in the Netherlands.

METHODS

In a 2-year nationwide prospective population-based cohort study, all ICU admissions during pregnancy, delivery and puerperium (up to 42 days postpartum) were prospectively collected. Incidence, case fatality rate and possible risk factors were assessed, with special attention to the ethnic background of women.

RESULTS

All 98 Dutch maternity units participated in the study. There were 847 obstetric ICU admissions in 358,874 deliveries, the incidence being 2.4 per 1,000 deliveries. Twenty-nine maternal deaths occurred, resulting in a case fatality rate of 1 in 29 (3.5%). Incidence of ICU admission varied largely across the country. Thirty-three percent of all cases of severe maternal morbidity were admitted to an ICU. Most frequent reasons for ICU admission were major obstetric haemorrhage (48.6%), hypertensive disorders of pregnancy (29.3%) and sepsis (8.1%). Assisted ventilation was needed in 34.8%, inotropic support in 8.8%. In univariable analysis, non-Western immigrant women had a 1.4-fold (95% CI 1.2-1.7) increased risk of ICU admission as compared to Western women. Initial antenatal care by an obstetrician was associated with a higher risk and home delivery with a lower risk of ICU admission.

CONCLUSIONS

Population-based incidence of obstetric ICU admission in the Netherlands was 2.4 per 1,000 deliveries. Obstetric ICU admission accounts for only one-third of all cases of severe maternal morbidity in the Netherlands.

[Peripartum cardiomyopathy: incidence, pathogenesis, diagnosis, treatment and prognosis]

INTRODUCTION

Peripartum cardiomyopathy (PPCM) is a rare and life-threatening disease of unknown aetiology. The primary objective of this review was to analysed aetiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis of this pathology.

METHODS

We undertook a systematic review of the literature using Medline, Google Scholar and PubMed searches.

RESULTS

Unlike other parts of the world in which cardiomyopathy are rare, dilated cardiomyopathy is a major cause of heart failure throughout Africa. Its aetiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. This diagnosis should be limited to previously healthy women who present with congestive heart failure (CHF) and decreased left ventricular systolic function in the last month of pregnancy or within 5 months after delivery. Recently, introduction of echocardiography has made diagnosis of PPCM easier and more accurate. Conventional treatment consists of diuretics, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. Patients who fail to recover may require inotropic therapy. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Prognosis is highly related to reversal of ventricular dysfunction. Compared to historically higher mortality rates, recent reports describe better outcome, probably because of advances in medical care. Based on current information, future pregnancy is usually not recommended in patients who fail to recover normal heart function.

CONCLUSION

PPCM is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Its aetiopathogenesis is still poorly understood. Introduction of echocardiography has made diagnosis of PPCM easier and more accurate. Prognosis is highly related to reversal of ventricular dysfunction.

A serious complication in the puerperium: peripartum cardiomyopathy

Two women, aged 27, presented with different symptoms shortly after giving birth to their first child. Peripartum cardiomyopathy (PPCM) was diagnosed. PPCM is a rare form of cardiac failure occurring late in pregnancy or in the postpartum period. Many women experience dyspnoea, fatigue, and pedal oedema in the last month of pregnancy or postpartum, symptoms which are identical to early congestive heart failure. Therefore, the diagnosis of PPCM requires vigilance. A high mortality rate and overall poor clinical outcome has been reported in a high percentage of these patients. Subsequent pregnancies remain controversial. (Neth Heart J 2008;16:415-8.).

Severe cardiac disease in pregnancy, part I: hemodynamic changes and complaints during pregnancy, and general management of cardiac disease in pregnancy

PURPOSE OF REVIEW

Part I of this review gives an overview of the hemodynamic changes that occur in normal pregnancy, the approach to the pregnant patient with complaints during pregnancy, and the general management of cardiac disease in pregnancy.

RECENT FINDINGS

The maternal circulatory adaptation to pregnancy consists almost entirely of adaptive changes in the maternal cardiovascular system in response to a primary systemic vasodilatation. Conversely, hemodynamic maladaptation consists of a combination of absence of these changes with signs of sympathetic dominance in the autonomic control of the cardiovascular system.

SUMMARY

The hemodynamic changes of normal pregnancy per se have profound effects on preexisting cardiac function. Counseling of and care for this subset of patients are challenging for the obstetrician, cardiologist, anesthesiologist and, sometimes, the intensivist to optimize maternal and neonatal survival.

Successful Use of Levosimendan in a Patient with Peripartum Cardiomyopathy

This case represents the first reported use of levosimendan, a calcium-sensitizing drug with additional vasodilation properties, for treatment of a woman with peripartum cardiomyopathy. Levosimendan induced a steady decline of increased pulmonary capillary wedge pressure, followed by a definitive increase in cardiac stroke volume. The patient recovered from this serious episode of heart failure, and she ultimately regained left ventricular function.

IMPLICATIONS

Acute heart failure is a life-threatening event that only rarely occurs during childbirth. We report a case of a woman who experienced cardiovascular collapse during vaginal delivery. We determined that she met current diagnostic criteria for peripartum cardiomyopathy, and we successfully treated her with levosimendan, a calcium-sensitizing drug with additional vasodilation properties.