Morning Report: 4/12/2013

Today’s Morning Report is courtesy of Dr. Semenovskaya!

Peripartum Cardiomyopathy

Background

– PPCM: Idiopathic cardiomyopathy that presents with heart failure secondary to left ventricular systolic dysfunction, typically manifesting in the last month of pregnancy and up to the first four months post-partum.

– Etiology is unknown – theories include associations with viruses, autoimmune disease, and unmasking of underlying cardiac pathology.

– Effects approximately 1000 women in the US annually; African Americans have a 17 times greater occurrence. Also more common in multiparous women.

– Mortality rate is 20 – 50%, in those who survive, more than half will have a complete recovery

Work-Up / Differential

– Physical findings: JVD; Rales/ ronchi, decreased breath sounds; Muffled heart sounds; Pitting edema; Hepatomegaly (venous congestion)

– Remember to consider: Preeclampsia, pulmonary embolism, drug/ alcohol related cardiomyopathy, non-cardiogenic pulmonary edema, malignant hypertension, mitral or aortic stenosis…

– Laboratory studies:

Cardiac enzymes (CPK can be normally elevated after a delivery; Troponin-I elevations more likely to indicate true myocardial disease)
BNP, >500 is indicative of CHF, exacerbation
CBC – elevated LFTs, thrombocytopenia suggest HELLP/ preeclampsia
Exclude other causes: TSH/ free T4, Urinalysis (proteinuria)

– Imaging:

CXR, pulmonary sonography (effusions); EKG
Echocardiography – EF, pericardial effusion
Consider CTA to r/o PE (pts at increased risk, consider in clinical context)

Acute Treatments and Interventions (*can use in pregnancy)

– IV, monitor, 02!

– Goals in treating CHF: Decrease preload, decrease afterload, increase inotropy!

– BiPAP*: Decreases work of breathing, decreases preload and afterload (but watch the blood pressure), recruits alveoli and keeps them open (improved ventilation), increases FRC. Can buy time and help correct hypoxemia and hypercapnia – once you’ve intubated, you’ve lost!

– Preload reduction with Nitrates*, Loop diuretics*, Hydralazine, morphine also useful. Be wary of volume depletion.

– ACE inhibitors*/ ARBs: interrupt renin-angiotensin-aldosterone feedback, decrease afterload; improves mortality

– Dobutamine, Dopamine, Digoxin: useful for hypotensive patients; improve inotropy

References:

– Peri-partum Cardiomyopathy: http://emedicine.medscape.com/article/153153-overview#a1

– Emergency Department Evaluation and Management of Peripartum Cardiomyopathy: http://www.medscape.com/viewarticle/588706