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June 21, 2012 Balderama-Mendieta. OBJECTIVES. Identify pertinent findings from the history and physical examination that would contribute to the diagnosis of peripartum cardiomyopathy Provide a systematic approach in diagnosing patients with peripartum cardiomyopathy
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June 21, 2012 Balderama-Mendieta
OBJECTIVES • Identify pertinent findings from the history and physical examination that would contribute to the diagnosis of peripartumcardiomyopathy • Provide a systematic approach in diagnosing patients with peripartumcardiomyopathy • Determine supportive diagnostic examinations • Arrive at a definitive diagnosis • Learn how to conservatively manage patients with peripartumcardiomyopathy
Patient Profile • 32 year-old , Female • Single, Filipino, Roman Catholic • From Quezon City • Admitted for the 1sttime at our institution on November 30, 2011
Patient Profile • Merchandiser • Drinks 2 liters of fluid per day, rarely drinks coffee • Doesn’t drink alcoholic beverages • Denies smoking and taking illicit drugs
Patient Profile • Rents the 1st floor of a 4-storey studio type apartment • Sufficient source of water and electricity in the neighbourhood • Garbage collected twice a week
Chief Complaint • Difficulty of breathing of few hours Source and Reliability • The patient herself with fair reliability
Past Medical History • Anterior Neck Mass, T/C Nodular Non-toxic Goiter, Biochemically and Clinically Euthyroid – November 2, 2011
Maternal History • Menstrual History • Menarche at 16 y/o, regular, 28-day cycle, 3 days duration, moderately soaked, 3 pads per day, no dysmenorrhea • Obstetrical History: G2P1 (1011) • G1- 2004, Spontaneous abortion • G2- 2011, LFT male via NSD, delivered at a lying-in-clinic by a mid-wife
Gynecologic History • History of pelvic infection, UTI at 16 3/7 weeks AOG of G2 (treated with Cefuroxime 500 mg/tab BID, resolved) • Sexual History • Coitarche at 23 y/o, 2 SP, no post coital bleeding or dyspareunia • Contraceptives History • None
Family History • Hypertension, CVD, and asthma – paternal and maternal sides
CONGESTIVE HEART FAILURE vs. PERIPARTUM CARDIOMYOPATHY.
Imp: PERIPARTUM CARDIOMYOPATHY • Peripartum cardiomyopathy is diagnosed using four criteria based on the work of Demakis et al 1971. • Development of cardiac failure in the last month of pregnancy or within 5 months of delivery • Absence of an identifiable cause for the cardiac failure • Absence of recognizable heart disease prior to the last month of pregnancy • Additional echocardiographic measures were included with the benefit of echocardiographic findings: • Left ventricular systolic dysfunction described as ejection fraction of less than 45%, fractional shortening of less than 30% or both, and end diastolic dimension of greater than 2.7cm/m2 body surface area.
Hypotheses of PPCM • Myocarditis • Abnormal Immune Response to Pregnancy • Response to Hemodynamic Stresses of Pregnancy • Other causes: • Prolonged tocolysis • Stress-activated Proinflammatory cytokines such as TNF a or IL-1 • Abnormalities of relaxin • Deficiency of Selenium
Management • Treatment is essentially the same with dilated cardiomyopathy • Goals: • To reduce to amount of volume returning to the heart (preload reduction) • To decrease the resistance against which the heart must pump (afterloadreduction) • To increase the contractile force of the heart (inotropy).
Preload and afterload reduction • Loop diuretics (caution in women with preeclampsia) • Hydralazine, nitrates and beta blockers • Inotropy • Digoxin (unless contraindicated) • Dobutamine, dopamine, milrinone • Prophylaxis for thromboembolism • Low dose heparin
Immunosuppressive therapy may be needed if peripartumcardiomyopathy is considered to be the result of myocarditis. • Patients should have a low sodium diet (≤ 4 gm) and fluid restriction (≤2L). • Activity should only be limited depending on the patient’s symptoms.
Cardiac transplantation and left ventricular assist devices are considered for women with progressive left ventricular dysfunction or deterioration despite medical therapy, however since most patients improve over time, surgical therapy should be delayed if possible.
Suggested Treatment Plan • Institute ACE inhibitor therapy with enalapril 5 mg twice daily and titrate up to a maximum dose of 20 mg twice daily, yet maintain SBP to 100 -110 mm Hg. • Start digoxin to achieve a serum level of 1 to 2 ng/dl. • Start diuretic therapy (furosemide 20 to 40 mg once daily) to control symptoms related to volume excess. *Peripartumcardiomyopathy: A comprehensive review American Journal of Obstetrics and Gynecology - Volume 178, Issue 2 (February 1998)
Start low-dose beta-blocker therapy (i.e., metoprolol 12.5 mg twice daily) and titrate for heart rate 80 to 100 beats/min. • Add additional vasodilator agents as needed to control systemic blood pressure (e.g., goal is systolic blood pressure 110 mm Hg). • Monitor ambulation for 24 to 48 hours.
Dietary consultation for fluid-restricted, low-salt diet. • Detailed patient education and counseling. • Referral to exercise rehabilitation program. • Vigilant follow-up to include measure of cardiac function within 3 to 6 months of treatment onset.
Prognosis • Prognosis depends on return to normal left ventricular function after the first episode of CHF. • In a study by Damaskis et al, they have observed that if the congestive cardiomyopathy persists after 6 months, it is likely irreversible and associated with a worse survival. • Recent studies have found that 30% of patients return to their baseline function after 6 months if given timely medical treatment.
Prognosis • Mortality rate is 10% and the usual causes of death include progressive heart failure, arrhythmia, or thromboembolism. • Patients who have peripartumcardiomyopathy are advised to avoid subsequent pregnancies due to concerns about the hearts inability to handle the increased cardiovascular workload during pregnancy.
