Location
RIPSHIN MTN. ROOM 130
Start Date
4-12-2019 11:40 AM
End Date
4-12-2019 11:55 AM
Faculty Sponsor’s Department
Obstetrics & Gynecology
Name of Project's Faculty Sponsor
Dr. Racine, Nita Edwards-Silva
Type
Oral Presentation
Project's Category
Cardiovascular Disease, Maternal Health, Public Health
Abstract or Artist's Statement
Introduction: Peripartum Cardiomyopathy (PPCM) affects 1 in 3,000 pregnancies and accounts for 5% of heart transplants in US women. Preeclampsia is one of the Hypertensive Disorders of Pregnancy (HDOP) that has been epidemiologically associated with PPCM which is a form of dilated cardiomyopathy. This concurrent clinical presentation of PPCM with associated Preeclampsia appears to be increasing in rural Northeast Tennessee. The diagnosis of Peripartum Cardiomyopathy is made by echocardiographic criteria of left ventricular dysfunction with LVEF
Case Presentation: A 22 year old G2P0010 @ 33 weeks and 1 day gestation was accepted as a transfer of care from an outside hospital. Patient had no prenatal care, was homeless, had a history of depression and polysubstance abuse. She presented with abdominal pain, shortness of breath, coughing, and unknown due date. Vitals on presentation were BP 175/99 mmHg, HR 113, respiratory rate 32, and temperature 99.2. Lab results showed elevated AST/ALT 234/102, LDH 903, Uric Acid 7.0, WBC 26.2, and BNP 1935. The 24 hour urine total protein resulted 4455 mg. Transthoracic echocardiogram revealed LV ejection fraction of 30 to 35% with global hypokinesis of the LV wall. The CXR was consistent with bilateral infiltrates and pulmonary edema. She was admitted to L & D and given a dose of Betamethasone for fetal lung maturity. Fetal heart tracing showed a baseline of 145 bpm with minimal variability and no accelerations or decelerations. The tocodynamometer showed contractions q 3-5 minutes and the ultrasound evaluation showed cephalic presentation. Social work and Cardiology consults were obtained. The clinical diagnoses of Peripartum Cardiomyopathy, Preeclampsia with severe features, and Bilateral Pneumonia were made and treatment included Lasix, Metoprolol, Magnesium Sulfate, Ceftriaxone, and Azithromycin. A primary low transverse cesarean delivery was performed with a live female infant weighing 1920 grams, 4 pounds 4 ounces, and Apgars: 6, 8. The patient was discharged home on Metoprolol XL 25 mg bid, Lisinopril 10 mg daily, Procardia 30 mg daily, Lovenox 40 mg daily, and Depo-Provera for contraception. Patient was informed that she would need a repeat echocardiogram in 3 months to assess left ventricular function.
Discussion: In this Appalachian region, there is an increased occurrence of Peripartum Cardiomyopathy presenting concurrently with Preeclampsia. These two combined clinical entities increase maternal morbidity and mortality. From a public health perspective, this clinical case highlights the psychosocial factors such as poverty, homelessness, polysubstance abuse, and depression that may have contributed to the clinical disease. The distinct features of this preterm antepartum case of PPCM are a younger, Caucasian primigravida with singleton gestation. Healthcare providers should have heightened awareness of this clinical presentation, especially in the postpartum period.
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The Unique Interplay of Peripartum Cardiomyopathy and Preeclampsia in an Appalachian Obstetric Patient.
RIPSHIN MTN. ROOM 130
Introduction: Peripartum Cardiomyopathy (PPCM) affects 1 in 3,000 pregnancies and accounts for 5% of heart transplants in US women. Preeclampsia is one of the Hypertensive Disorders of Pregnancy (HDOP) that has been epidemiologically associated with PPCM which is a form of dilated cardiomyopathy. This concurrent clinical presentation of PPCM with associated Preeclampsia appears to be increasing in rural Northeast Tennessee. The diagnosis of Peripartum Cardiomyopathy is made by echocardiographic criteria of left ventricular dysfunction with LVEF
Case Presentation: A 22 year old G2P0010 @ 33 weeks and 1 day gestation was accepted as a transfer of care from an outside hospital. Patient had no prenatal care, was homeless, had a history of depression and polysubstance abuse. She presented with abdominal pain, shortness of breath, coughing, and unknown due date. Vitals on presentation were BP 175/99 mmHg, HR 113, respiratory rate 32, and temperature 99.2. Lab results showed elevated AST/ALT 234/102, LDH 903, Uric Acid 7.0, WBC 26.2, and BNP 1935. The 24 hour urine total protein resulted 4455 mg. Transthoracic echocardiogram revealed LV ejection fraction of 30 to 35% with global hypokinesis of the LV wall. The CXR was consistent with bilateral infiltrates and pulmonary edema. She was admitted to L & D and given a dose of Betamethasone for fetal lung maturity. Fetal heart tracing showed a baseline of 145 bpm with minimal variability and no accelerations or decelerations. The tocodynamometer showed contractions q 3-5 minutes and the ultrasound evaluation showed cephalic presentation. Social work and Cardiology consults were obtained. The clinical diagnoses of Peripartum Cardiomyopathy, Preeclampsia with severe features, and Bilateral Pneumonia were made and treatment included Lasix, Metoprolol, Magnesium Sulfate, Ceftriaxone, and Azithromycin. A primary low transverse cesarean delivery was performed with a live female infant weighing 1920 grams, 4 pounds 4 ounces, and Apgars: 6, 8. The patient was discharged home on Metoprolol XL 25 mg bid, Lisinopril 10 mg daily, Procardia 30 mg daily, Lovenox 40 mg daily, and Depo-Provera for contraception. Patient was informed that she would need a repeat echocardiogram in 3 months to assess left ventricular function.
Discussion: In this Appalachian region, there is an increased occurrence of Peripartum Cardiomyopathy presenting concurrently with Preeclampsia. These two combined clinical entities increase maternal morbidity and mortality. From a public health perspective, this clinical case highlights the psychosocial factors such as poverty, homelessness, polysubstance abuse, and depression that may have contributed to the clinical disease. The distinct features of this preterm antepartum case of PPCM are a younger, Caucasian primigravida with singleton gestation. Healthcare providers should have heightened awareness of this clinical presentation, especially in the postpartum period.