hys case report
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L/O/G/O
CASE REPORT 2014
PERIPARTUM CARDIOMYOPAHariyasa Sanjaya
Fetomaternal Division, OBI! De"artment, Me#i$al Fa$%lty,U#a ana Universit San la' eneral Hos ital Den asar Bali I
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July 29, 2013
Name : DUR Age : 26 years old
Occua!"o# : $ouse%"&e 'duca!"o# : Ge#eral $"g( )c(ool
IDENTITY
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*a"# comla"#! :Dys#ea s"#ce 3 days +e&ore (os"!al"ed,
-#o%# (yer!e#s"o# s"#ce ge#eral ("g( sc(ool,
out of schedule visit to OPC
L*. : /1/2013
'DD : 1/10/2013
.N : OG s"#ce GA 20%2d
ANAMNESIS
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Obstetric history :
)( *, IUFD, A + m(o, San&la' 'os"ital,-))
( ., /-- &rams, Termination e($Im"en#in& e0lam"sia, San&la''os"ital, -), 1
3. Current pregnancy
Married 1x~3 years
Contraception (-)
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PHYSICAL AND OBSTETRIC EXAM
Present St :BP : 160/110 mmHg
RR : 32 x/menit
P : 132 x/menit
tax : 36,8 C⁰
General St :
Thorax :
Co : S1S2 single, reguler,
murmur (+)
Po : ves +/+, rhonchy+/+, wh -/-
!stre"ities : #e"a -/-
+/+
$%stetri& St :'%#o"en : () 3 *ingers a%ove u"%ili&al no uterine &ontra&tion, () :12 %"
.T :C 1 &", e** 20, '+
)ea# ala%le, #eno"inator un&lear,
4) 5, unala%le s"all arts/u"% &or# US :
(etus S/, () +, (+ '. : 28w6# : 1/17/2713 ( : 1291 gra"s Pla&enta &orus anterior gr 55 '(5 1,1
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DIAGNOSTIC AND CONSULT
o Thorax P' 29/;/2713 :Pul"onar< e#e"a an# ilateral leural e**usion
Pre!iou" #choc$r%iogr$&hy (13/11/2012) :
'roriate to )), Se&on#ar< o#erate, ' il#, S<stoli&
*un&tion . =or"al( %ilane 660
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Consult fro ot!"r #"$%rt"nt&
'#R* 29/;/2713 :' : Sueri"ose# P
Tx : eth<l#oa 2x27 "g
o
=i*e#iine 3x17 "g o
)al* sitting osition
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*R'-.- 29/;/2713* : HH
R mo%er$te, *R i%
# 66 4
H "t '' e5c Su&erim&o"e%
P# #S occ$"ion$
Pumon$ry e%em$
Suggest: eth<l#oa 3x12 "g o
=i*e#iine 3x27 "g o
Planning : eeat &ho&ar#iograh<
a% 29/;/2713
Protein +1
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Ax :
G3!"!! "# $%s& '& *O+& 'uperi,posed &pu,onary ede,a
> ')( Pro*ile e?& eriartu" #ilate# &ar#io"<oath<
> ' "il#, "o#erate, P "il#, T "il#, ( 2@ 0 dx : -
/x :- O" 0 p,
- conseratie bed rest $ith se,i2o$er position
- MgSO4
- exa,ethasone 1x1" ,g 4M (" days)
- 5i2edipine 3x1! ,g po
- Other therapy as per as 4nterna and Cardioogy ept.
DIA'NOSIS AND MANA'EMENT
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6 day ater
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1 "t 7-' -#R##:
4 - -S#R*'# until G' 3@ w!s #ue to atient reAuest
- )ositaliBe#
4 *R'-.- :&lose "onitoring, "onitoring volu"e with &ontinuous
CG 2-3 #a<s, "axi"iBe *# inhi8itor, i"rove"ent + will %erela&e# with 8et$ 8oc9er
- -B : will %e hel# *etal assess"ent an# et$ "u&&y ine assess"ent?
(or "other : sitting osition, ox<genation, oti"iBing
- P#'*R' : =5CD, stan# %< ventilator a*ter #eliver< #is&ussion with
"anage"ent an# "e#i& &o""ittee *or sur*a&tant not covered by
jampersal
- #PHR-.- : treat in*e&tion anti%ioti&
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7eta Assess,ent
4(etus Singleton, live, () +, ( +, hea# resentation
4 37 wee! 1#a<
4( : 1@89 E170
4'(5 : 13,3
4S/ atio : 2,6
45 : 7,1
4P5 : 7,;9
4Pla&enta anterior gra#e 55
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"nd 8O45/ CO5795C
- Patient in 5CCD until G' 3@ wee!
- onitoring e&ho&ar#iograh< #a<s
-'C 5nhi%itor with "onitoring #oler velo&i"etr< *etal renalis
arter<-5* "other or *etus &on#ition worsening then e"ergen&< CS will
%e er*o"e#?
-DSG oler velo&i"etr< in one wee!
-CC F Hemostatic profile ever< 3 #a<s
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Car#iolog<:
' : ')( Pro*ile i"rove# et&?
ilate# &ar#io"<oath</(C 555
"o#erate, ' "il#, T "il#, P
"il#
G3P7727 31-32 w!s?, S/, $
Sueri"ose# P
DSG aternal (etal:
(etus S/, () +, ( +, hea#
res
'. : 37w2# : 27/17/2713
( : 19@ g
Pla&enta *un#us &orus anterior gr 55
'(5 : 12,;
D"%ili&al arter< :
S/ :3,;1, 5 :7, ;3, P5 : 1,@2
DSG aternal (etal:
(etus S/, () +, ( +, hea# res
'. : 31w7# : 22/17/2713
( : 1;6 g
Pla&enta &orus anterior gr 55
'(5 : ;,19
D"%ili&al arter< :
S/ : 3,13, 5 : 7,68, P5 : 1,1;' : G3P7727 32-33 w!s, S/, $)
Sueri"ose# P, ')( ro*ile e?&
#ilate# &ar#io"<oath< eriartu"/(C
555, "o#erate, ' "il#, P "il#,
T "il#, eAuivo&al oligohi#a"nion
( : 1;6 gP#x
Tx : C-se&tion 21/8/2713 at
$erating Central oo"
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"1 days ater
4 ale %a%< was %orn %< ele&tive C- Se&tion
1337 gra" , 'S : ;-8 =S : 22 32-33 wee!
SG', CT. + right an# le*t *oot
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"0 days ater
4S : Su##enl< not a%le to sea!, Mouth weakness to the left
4$ : P 137/177 "")g
4' : - S=) e?& e"%oli ##/thro"%oe"%olis"
4 ##/ thro"%us
4 - P7371 ost CS #a< .555 *ollow u4 Sueri"ose# P
4 - ')( ro*ile e?& #ilate# &ar#io
4 "<oath< eriartu" (C 555
4 - "o#erate, ' "il#, P "il#,
4 T "il#
4S Sc$n :
4Su8 $cute i"chemic cere8r$ in$rction $t right tem&or$ o8e
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3rd 8O45/ CO5795C
euroogy :
-'&etosal, Citi&olin,, o%oransia
4-Suggest reeat CT S&an #a< 555 %e&ause &lini&al insigni*i&an&e to ra#iologi& result
4-Suggest Trans Cranial oler TC to #eter"ine the &ause o* S=) not urgent
4-Patient "ove# to awar ar#
*ne"the"i$ :
4-i#ural anesthesia given %e*ore ha# less e**e&t to S=)
4-i#ural anesthesia will %e re"ove# soon an# rela&e# with oral analgesi&
-B :
- Breastfeed &ontinue, with #ail< Catoril as treat"ent-Give attention to "other s<&h, Give &han&e *or "other-&hil# &onta&t %< au#io visual
"e#ia ai#
-Consult to Rehab medic dept. and clinical nutrition
- =eurolog< has the "ost i"ortant role *or the next &are
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#PHR-.- :
4-'gree to &ontinue Catoril
*R'-.- :
4-aintain atient 'P
4-Catoril is not a &ontrain#i&ation *or breastfeed
P#'*R' :
4-=ow ( is 1@77 g, no in*e&tion =5CD &are with "o#erate rognosis
4-Pro%le"s :
4 - Haun#i&e %iliru%in 13 "g/#l hotothera<4 -CT. &onsult orthoe#i&: will %e treate# with serial cast
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3rd 8O45/ CO5795C
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3 days ater
4 Mother $as discharge ho,e andcontinue $ith outpatient care
4 *aby sti ie unti today $ith goodcondition
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'5clus"o# d"ag#os"s
cr"!er"a +ased o# N$L7 :
1. Heart failure in the end of pregnancy or
within 5 months after delivery 2No re8"ous (ear! d"sease
3No "de#!"&"ed cause o& (ear! &a"lure
Le&! 8e#!r"cle sys!ol"c dys&u#c!"o# ec(ocard"ogra(y cr"!er"a
"ll"ams et al , 200;<
PERIPARTUM CARDIOMYOPATHY
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;A2ro-A,erican race : 11<"1 delivery
;+ispanic race : 1#061 delivery
;Caucasian race : 1<!= delivery
;Asia race : 1"6= delivery
(*rar et al& "!!=)
INCIDENCE
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> Mother age ?3! y.o> +ypertension (reeca,psia)
> A2rica-A,erica race
> Mutiparty> Mutipe gestation
> Obesity
(Mishra et al&"!!6)
RIS( )ACTOR
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> Myocarditis> Abnor,a i,,une response to pregnancy
> Maadaptie response to he,odyna,icstress in pregnancy
> Cyto%ine stress-actiated
> roonged tocoytic
> 9eaxin abnor,aity
> 'eeniu, de@ciency
(earson et al& "!!!)
ETIOLO'Y
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> suay postpartu,> 'i,iar $ith nor,a postpartu, sy,pto,
(dyspnea& s$eing& 2atigue)
> too ate to %no$n by diagnostic
> /ypica heart 2aiure signs and sy,pto,s :
- dyspnea
- orthopnea
- cough
(Biia,s et al& "!!0)
SI'NS AND SYMPTOMS
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> Other sy,pto,s :
- 7atigue
- 5onspeci@c heart burn
- Abdo,ina pain
> Low incidence :- 'yste,ic e,boi cause o2 e2t entrice
dys2unction
- Acute ,yocardia in2arct cause o2 inadeuate
coronary artery per2usion
(Biia,s et al& "!!0)
SI'NS AND SYMPTOMS
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P'ysi$al e2amination
(typically to Heart Failure):
- +ypoxia
- 8uguar ein distension
- '3 Gaop- Crac%es
- +epato,egay
34illiams et al , --/5
SI'NS AND SYMPTOMS
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> CG : - sinus tachycardia
- nonspeci@c changes '/-/
- e2t entrice hypertrophy
- conduction abnor,aity : ***
> Chest D-ray : cardio,egay and pu,onary eincongestion or pu,onary ede,a& $ith or $ithoutpeura eEusion
> Echocardiography : diatation e2t atriu, andentrice& decrease o2 eFection 2raction and
2ractiona shortening
(Biia,s et al& "!!0)
DIAGNOSTIC SUPPORT
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> T'ree "rin$i"les 6
7 )(De$reasin& "reloa# 6 nitrate, #i%reti$
7 (De$reasin& a8terloa# 6 'y#rala9ine, ACE
in'i:itor 3"ost"art%m5
7 ;(In$reasin& inotro"i$ 6 :eta :lo$0er
> 4,,unogobuin
> igoxin& dopa,ine& dobuta,in (hypotension)
> Anticoaguant (bood stasis)
> ace,a%er (entricuar arrhyth,ia)> +eart transpant
(Biia,s et al& "!!0)
MANA'EMENT
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> epends on nor,aiation e2t entrice sieand 2unction in 6 ,onths postpartu,
> ! H o2 entrice 2unction recover in 6
,onths postpartu,> Fractional shortening <2! " de#and end
diastolic o$ le$t ventricle % & c# ris' o$ persistence le$t ventricle dys$unction
(Abboud et al& "!!=)
PRO'NOSIS
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> "! H patients $ith peripartu,cardio,yopathy died or had hearttranspant
>Bo,en $ith persistent e2t entricedys2unction $i increase ris% o2 preter,abor and ,aterna death
(Biia,s et al& "!!0)
PRO'NOSIS
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L/O/G/O