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PERIPARTUM CARDIOMYOPATHY

Sanjay Rao*, Pk Shah***, Divyani Makwana**,Sheetal Dholakia**, Pankaj Wani**
*Lecturer; **Sr. Resident; ***Professor; Department of Obstetrics and Gynaecology, LTMG Hospital and LTMM College, Sion, Mumbai - 400 022.

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INTRODUCTION

Peripartum cardiomyopathy is a unique form of idiopathic myocardial degeneration and fibrosis associated with congestive cardiac failure that is intimately related to pregnancy.

CASE REPORT

Mrs. NAP, a 21 year old hindu housewife was admitted on 4.8.1999 in the intensive cardiac care unit at LTMG Hospital. She was a second gravida with previous history of one spontaneous abortion. She had 9 months amenorrhoea and c/o acute onset of palpitations since one day. She was antenatally registered at a peripheral hospital and was immunized for tetanus. She had no significant medical or surgical illnesses in the past. Her LMP was on 4.11.98 and past cycles were regular, EDD was on 11.8.99. On general examination she was averagely built and nourished, with mild pallor. There was no cyanosis, icterus, clubbing or lymphadenopathy. Her pulse was 160 bpm, irregular, with missed beats, all peripheral pulses were well felt. The respiratory system showed a normal air entry and there was tachycardia on auscultation of the heart. Per abdominally there was single full term foetus in breech presentation. The patient was in active labour within three hours of admission and had a 2.3 kg full term male child by assisted breech delivery at 5.30 am on 5.8.99 with a good Apgar score. There were no third stage complications. An electrocardiogram taken in the ICCU showed a flutter pattern with the atrial rate between 250 and 300 bpm and diffuse ST-T wave changes. The patient was given complete bed rest and nasal oxygen. She was started on digoxin therapy and prophylactic antibiotics. Baseline haematological investigations were within normal limits and serum electrolytes S. Na 133 mEq/Lt. After stabilization of the heart rate a 2D ECHO revealed an enlarged left ventricle and reduced ejection fraction suggestive of peripartum cardiomyopathy. The patient gradually improved symptomatically and was continued on rest and digoxin therapy. She was discharged with her baby three weeks later. She was counselled about barrier contraception and continued on digoxin therapy. She has been advised to follow up at the cardiology and postnatal OPDs regularly.

DISCUSSION

Peripartum cardiomyopathy appears in one of every 4000 to 5000 live births. Though the syndrome was referred to as postpartum cardiomyopathy or puerperal heart failure, the signs and symptoms may appear at any time in the last month of pregnancy and upto five months after delivery and hence the name peripartum cardiomyopathy is used more frequently. The majority of patients with peripartum cardiomyopathy are 20 to 35 years of age and seek treatment in the second or third postpartum month for weakness, shortness of breath, orthopnoea, cough, paroxysmal nocturnal dyspnoea and palpitations. [2] Physical examination reveals tachycardia, cardiac arrhythmias, pulmonary rales and peripheral oedema. Chest X-ray examination shows an enlarged heart and pulmonary vascular distribution. Echocardiography findings demonstrate chamber enlargement, predominantly left ventricular hypertrophy, decreased ejection fraction and cardiac output and increased pulmonary wedge pressure. Some patients could develop deep vein thrombosis and pulmonry embolization. Bed rest, digitalis, diuretics and anticoagulants form the mainstay of treatment in patients with peripartum cardiomyopathy. [1] 50-60% of patients have spontaneous recovery of cardiac function within six months of the onset. [3] The remainder either have persistent ventricular dysfunction or deteriorate; to die early or to receive cardiac transplantation. [4] There is a tendency towards recurrence with subsequent pregnancies. [5]

Hence a previous history of peripartum cardiomyopathy is a relative contraindication tohave a repeat pregnancy in mothers who have recovered normal cardiac function and an absolute contraindication to have a pregnancy when there is persistent left ventricular dysfunction.

REFERENCES

1. Fernando Arias. Part three : Cardiac disease and pregnancy. Practical guide to high risk pregnancy and delivery : second edition. 1993; 213.

2.Harrison’s Principles of internal medicine, 14th edition. The cardiomyopathies and myocarditis, Joshua Wynne, Eugene, Braunwald. 239 : 1330.

3.Lampert MB, Weinert L, Hibbard J, et al contractile reserve in patients with peripartum cardiomyopathy and recovered left ventricular function. Am J Obstet Gynecol 1997; 176 : 189-95.

4.Bertrand E. Post - Partum cardiomyopthy : Medical aspects, role of heart transplantation. Arch Mal Coeur Vaiss 1995; 88 : 1635-40.

5.St John Sutton M, Cole P, Plappert M. Effects of subsequent pregnancy or left ventricular function in peripartum cardiomyopathy. Am Heart J 1991; 121 : 1776.

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