Morning Report: 8/29/2013

Thanks to Dr. Waldman for today’s Morning Report!

PERI-PARTUM CARDIOMYOPATHY (PPCM)

Case: 35 yo F G1P1 no PMH presents 5 days s/p c-section for arrest of delivery comes ℅ BLE edema for the last 2 days a/w SOB. Pt denies the presence of edema during her pregnancy or any personal or familial history of DVT/PE. Exam is remarkable for 2+ bilateral pitting edema to the knees, lungs CTAB.

Differential Diagnosis:

CHF
renal disease
hepatic disease
pre-eclampsia
malnuitrition
DVT
valvular disease
peri-partum cardiomyopathy

Causes ???

infectious (EBV, CMV, HSV)
genetic
pre-eclampsia
fetal cells present in the maternal system that elicit an inflammatory response

Physical Exam: In a patient with PPCM, signs of heart failure are the same as in patients with systolic dysfunction who are not pregnant.

Tachycardia
Decreased pulse oximetry (should be ≥ 97% at sea level).
Blood pressure may be normal. (systolic >140 mm Hg and/or diastolic >90 mm Hghyperreflexia with clonus suggest preeclampsia).
Elevated jugular venous pressure
Third heart sound (turbulent ventricular filling secondary to poor wall relaxation from dilated ventricle)
Loud pulmonic component of the second heart sound (increased right sided flow)
Mitral or tricuspid regurgitation
Pulmonary rales
Peripheral edema
Ascites
Hepatomegaly

Testing, testing 1, 2, 3:

cbc (thrombocytopenia)
comprehensive metabolic panel (creatinine, LFTs, albumin)
urine dipstick
for our medicine folk… 24 hr urine creatinine clearance, serologic testing (rickettsia, HIV, syphillis, Chagas, diptheria toxoid), thyrotoxicosis, ethanol, cocaine, collagen vascular diseases, sarcoidosis, pheochromocytoma, acromegaly (this is getting ridiculous)
EKG
echocardiogram:urgent, to assess ventricular function
CXR
stress testing

Treatment:

Medical Therapy

○ Digoxin: first line in pregnancy

○ Loop diuretics; Start with 10 mg of furosemide, as pregnant women have an increased glomerular filtration rate (GFR) that facilitates secretion of the drug into the loop of Henle.

○ Hydralazine and nitrates: afterload and preload reduction and

○ Beta-adrenergic blockade with carvedilol or metoprolol succinate: decrease all-cause mortality and hospitalization in those with systolic dysfunction.

○ Heparin: for EF<30% (high risk of venous and arterial thrombosis)

Surgical Intervention

○ Cardiac transplant

○ Left ventricular assist devices

Dispo: ICU monitoring, consider transfer to a center that offers tertiary care services for both the mother and the fetus.

Delivery?? Unless the mother is decompensating, managing her medically and waiting for a spontaneous vaginal delivery is reasonable. If she is not responding to medical therapy or if the fetus must be delivered for obstetric reasons, the best plan is to induce labor with the goal of a vaginal delivery. Postoperative third-spacing of fluid that occurs after cesarean deliveries reverses after approximately 48 hours, leading to intravascular volume overload and possible maternal decompensation.