Peripartum Cardiomyopathy A Rare Cause of Pulmonary Oedema in Late Pregnancy

Abstract

A 23-year-old primigravida was admitted to hospital at 36 weeks' gestation because of marked peripheral edema and proteinuria. She was anemic but initially not hypertensive. Membranes ruptured spontaneously and she was transferred to the regional center with an infusion of ritodrine as a tocolytic agent. On arrival, her BP was 140/95 mmHg, proteinuria 2+, and moderate preclampsia was diagnosed. A lumbar pidural catheter was inserted and 0.25% bupivacaine 8 ml injected. She also received approximately 1500 ml of crystalloid IV. One hour later she complained of shortness of breath and chest pain, BP was 160/110 mmHg, HR 140 beats/min. Bilateral basal crepitations and chest X-ray confirmed pulmonary edema. She was given furosemide. CVP via an antecubital vein gave a reading of zero. Emergency cesarean section was performed under general anesthesia without complications. On recovery, BP was 150/110 mmHg, HR 110 beats/min and CVP 4 cm H2O. Diuresis was good in response to furosemide. However, during the night, she suffered an exacerbation of the pulmonary edema with a HR of 175 beats/min. She responded to further furosemide and diamorphine, but still remained in pulmonary edema. An ECG 2 days postpartum showed widespread T-wave inversion in the anterior leads. A balloon tipped flow-directed pulmonary artery catheter was inserted and showed a wedge pressure of 30 and pulmonary artery pressure of 44/35 mmHg. Echocardiography showed a dilated left ventricle and a low ejection fraction. She was treated with isosorbide infusion, digoxin and diuretics and improved gradually. Echocardiography again revealed a dilated left ventricle with poor contraction and also demonstrated mitral regurgitation and paradoxical movement of the septum. A diagnosis of peripartum cardiomyopathy was considered. The woman continued to improve and was discharged 18 days postpartum after complete radiologie resolution of pulmonary edema and cardiomegaly.