june 21, 2012 balderama-mendieta. objectives identify pertinent findings from the history and...
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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 cardiomyopathyDetermine supportive diagnostic examinationsArrive at a definitive diagnosis
Learn how to conservatively manage patients with peripartum cardiomyopathy
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
Review of SystemsGeneral (-) significant weight loss, (+) weight gain
Skin (-) lumps, (-) sores, (-) itching, (-) changes in color; (-) changes in hair or nails, (-) changes in size or color of moles,
Head (-) headache, (-) head injury, (-) dizziness and (-) light-headedness
Eyes (-) icteric sclerae, (-) pale palpebral conjunctivae
Ears Unremarkable
Nose (-) frequent colds,(-) discharge, (-) itching, (-) nosebleed
Throat (-) dentures, (-) hoarseness,(-) dry mouth, (-) frequent sore throats
Neck (-) swollen glands, (+) anterior neck mass, (-) lumps, (-) pain and stiffness
Review of Systems
Cardiovascular (-) dyspnea, (-) easy fatigability, (-) orthopnea, (-) palpitations
Gastrointestinal (-) dysphagia, (-) nausea and vomiting, (-) melena, (-) jaundice, (-) indigestion, (-) fatty food intolerance, (-) acholic stool, (-) changes in bowel movement
Urinary (-) polyuria, (-) nocturia; (-) hematuria, (-) retention, (-) bleeding
Genitoreproductive (+) gravidumstriae, (+) lineanigra, (+) gravid uterus
Musculoskeletal (+) swelling both feet, (-) redness, (-) no history of trauma
Respiratory (-) cough, (-) hemoptysis, (-) dyspnea, (-) wheezing, (-) tuberculosis
Review of Systems
Psychiatric (-) nervousness, (-) tension, (-) mood changes, (-) depression, (-) memory change
Neurologic UnremarkableHematologic (-) anemia, (-) easy bruising or bleedingEndocrine (-) excessive sweating, (-) excessive
thirst or hunger
Admitting Physical Examination
General Survey
Awake, alert, ambulatory, weak-looking, ectomorph, in cardiorespiratory distress
Vital Signs
BP 130/90; HR 109bpm; RR 25bpm; 36.1C
Admitting Physical Examination
Anthropometrics Height: 157 cm Weight: 48 kg BMI: 19.5
HEENT Anicteric sclerae, pink palpebral conjunctivae, no tonsillopharyngeal congestion, no cervical lymphadenopathies, distended neck veins
Admitting Physical Examination
Chest/Lungs Equal chest expansion, with subcostal retractions, dullness noted on both lower lung fields, decrease vocal fremitus on both lateral fields, decrease breath sounds on both lower lung field, noted with bibasal crackles
Admitting Physical Examination
Heart Adynamic precordium, tachycardic, regular rhythm, distinct S1 and S2, PMI at 5th ICS, MCL, no murmurs
Abdomen Globular, soft abdomen, NABS, no tenderness, no palpable masses
Admitting Physical Examination
Extremities Grade 3/5 pulses on all extremities, Grade 2 bipedal edema, cold extremities, no cyanosis
MSE Intact
Cranial Nerves
Intact
Complete Blood Count (11.30.11)11.30.11 12.03.11
Hemoglobin 181 g/L 151 g/LHematocrit 52% 45%RBC 5.7 x 1012/L 4.8 x 1012/LWBC 15.4x109/L 8.1x109/LNeutrophils 85% 56%
Lymphocytes 14% 36%Monocytes 4%
Eosinophils 3%
Basophils 1%
Platelets 442 x 109/L NormalRemarks Normochromic,
normocyticNormochromic, normocytic
Urinalysis (11.30.11)Color Light yellow
Turbidity Slight cloudy
Reaction Acidic
S. Gravity 1.015
Protein (++)
Sugar Negative RBC 20-25/hpfWBC 0-2/hpfCast NoneBacteria FewEpithelial Cells FewCrystals None
Mucous Threads None
Yeast Cells None
Arterial Blood Gas (11.30.11)
pH 7.45
pCO2 32 mmHg
pO2 60 mmHg
HCO3 22.20 meq/L
Base Excess (ECF) -1.80
O2 Saturation 92%
Total CO2 23.20
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 tocolysisStress-activated Proinflammatory
cytokines such as TNF a or IL-1Abnormalities of relaxinDeficiency of Selenium
Management Treatment is essentially the same with
dilated cardiomyopathy Goals:1. To reduce to amount of volume returning
to the heart (preload reduction)2. To decrease the resistance against which
the heart must pump (afterload reduction)
3. To increase the contractile force of the heart (inotropy).
Preload and afterload reductionLoop diuretics (caution in women with
preeclampsia)Hydralazine, nitrates and beta blockers
InotropyDigoxin (unless contraindicated)Dobutamine, dopamine, milrinone
Prophylaxis for thromboembolismLow dose heparin
Immunosuppressive therapy may be needed if peripartum cardiomyopathy 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 Plan1. 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.
2. Start digoxin to achieve a serum level of 1 to 2 ng/dl.
3. Start diuretic therapy (furosemide 20 to 40 mg once daily) to control symptoms related to volume excess.
*Peripartum cardiomyopathy: A comprehensive reviewAmerican Journal of Obstetrics and Gynecology - Volume 178, Issue 2 (February 1998)
4. Start low-dose beta-blocker therapy (i.e., metoprolol 12.5 mg twice daily) and titrate for heart rate 80 to 100 beats/min.
5. Add additional vasodilator agents as needed to control systemic blood pressure (e.g., goal is systolic blood pressure 110 mm Hg).
6. Monitor ambulation for 24 to 48 hours.
7. Dietary consultation for fluid-restricted, low-salt diet.
8. Detailed patient education and counseling.
9. Referral to exercise rehabilitation program.
10. 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 peripartum cardiomyopathy are advised to avoid subsequent pregnancies due to concerns about the hearts inability to handle the increased cardiovascular workload during pregnancy.