[Peripartum cardiomyopathy]

When a Peripartum Cardiomyopathy Patient Hides Various and Serious Risk Factors for Recurrent and Fatal Thromboembolic Events Even Under Well-Conducted Oral Anticoagulation

Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure that occurs during the final month of pregnancy through about five months after delivery, without any other known cause, and it increases the risk of thromboembolic events by many folds. A 38-year-old female with a history of peripartum dilated cardiomyopathy was admitted to our hospital, one month after a cesarean section, for severe breathlessness. Examination revealed signs of global heart failure and right deep vein thrombosis. Pulmonary CT angiography revealed pulmonary embolism of the right pulmonary artery. The patient was treated by oral anticoagulation with acenocoumarol with all international normalized ratio (INR) values within the target range (2-3). One month later, she was admitted to the emergency department with acute dyspnea and superior vena cava syndrome. Thoracic CT angiogram showed bilateral pulmonary emboli associated with an extensive deep vein thrombosis of both internal jugular veins, sigmoid sinuses, subclavian veins, innominate venous trunks, and the origin of the superior vena cava without any lesion suspected of malignancy. The thrombophilia screen performed six weeks after the suspension of vitamin K antagonists (VKAs) revealed severe deficiencies of protein C and protein S. In this report, we present the first case of recurrence of fatal thromboembolic events under well-conducted oral anticoagulation in a patient with PPCM associated with severe protein C and protein S deficiencies.

[Peripartum cardiomyopathy]

La cardiomyopathie du péri-partum (CMP-PP) ou syndrome de Meadows, est une cardiomyopathie dilatée survenue pendant ou au décours d'une grossesse, définie par une insuffisance cardiaque avec une fraction d'éjection systolique du ventricule gauche inférieure à 45%. Il s'agit d'une entité pathologique rare dont le mécanisme physiopathologique en cause reste mal élucidé. Sur le plan clinique il s'agit d'une insuffisance cardiaque inopinée d'installation rapide, d'évolution imprévisible avec risque de choc cardiogénique réfractaire justifiant une prise en charge en réanimation cardiovasculaire. La CMP-PP ne nécessite aucun traitement spécifique par rapport aux autres causes d'insuffisance cardiaque. Nous rapportons le cas d'une primigeste de 29 ans qui a consulté à 32 semaines d'aménorrhée dans un tableau d'insuffisance cardiaque congestive en rapport avec une cardiomyopathie du péri-partum. L'objectif de ce travail est de préciser les caractéristiques de cette cardiopathie, qui malgré son caractère exceptionnel ne doit pas être méconnu par l'obstétricien.

Sepsis and pregnancy: do we know how to treat this situation?

Sepsis is defined as an acute inflammatory response syndrome secondary to an infectious focus. It has a high incidence, morbidity and mortality, causing substantial financial costs, especially due to complications such as septic shock and multiple organ dysfunction. The pathogen toxins associated with individual susceptibility culminate with cytokine release, which promotes a systemic inflammatory response that can progress to multiple organ dysfunction and eventual patient death.

Specifically, sepsis incidence, morbidity and mortality are lower in pregnant women, as this group is typically younger with fewer comorbidities having a polymicrobial etiology resulting in sepsis.

Pregnant women exhibit physiological characteristics that may confer specific clinical presentation and laboratory patterns during the sepsis course. Thus, a better understanding of these changes is critical for better identification and management of these patients. The presence of a fetus also requires unique approaches in a pregnant woman with sepsis.

Sepsis treatment is based on certain guidelines that were established after major clinical trials, which, unfortunately, all classified pregnancy as a exclusion criteria.

Thus, the treatment of sepsis in the general population has been extrapolated to the pregnant population, with the following main goals: maintenance of tissue perfusion with fluid replacement and vasoactive drugs (initial resuscitation), adequate oxygenation, control of the infection source and an early start of antibiotic therapy, corticosteroid infusion and blood transfusion when properly indicated, prophylaxis, and specifically monitoring and maintenance of fetal heath.

Peripartum cardiomyopathy, an autoimmune manifestation of allograft rejection?

The timing of peripartum cardiomyopathy (PPCM) in association with pregnancy is typical of autoimmune conditions. This review addresses this fact by presenting PPCM as an organ specific autoimmune response (though not necessarily as an outright autoimmune condition), akin to autoimmune responses seen with complications of allogeneic organ transplantations. Since pregnancy represents a semi-allograft (representing paternal alloantigens), pregnancy and allogeneic organ transplants can be expected to be subject to similar allograft tolerance mechanisms, and also to share potential complications of normal allograft tolerance. This review suggests that PPCM represents a cardio-toxic autoimmune component within a more general immunological malfunction of tolerance of the fetal allograft by the maternal immune system. Treatment of PPCM with therapies, proven successful in graft versus host disease and organ rejection, may, therefore, be successful. Their success would also be confirmatory of such a concept.

Postpartum depression, an autoimmune disease?

Medical conditions with known etiology and typical peripartal/postpartal disease exacerbations are now, without exception, considered autoimmune in etiology. Postpartum psychiatric conditions, and especially postpartum depression, currently, however, are still not understood in their etiology. This paper suggests that the typical postpartum flare pattern, and other clinical characteristics, point towards an autoimmune etiology for (postpartum) depression. The high prevalence of (postpartum) depression led to its designation as a major public health problem. A better understanding of etiology and pathophysiology would greatly advance the, currently still inaccurate, diagnosis of the condition, and improve approaches towards prevention and treatment.