Peripartum cardiomyopathy

Sliwa, Karen; Fett, James D.; Elkayam, Uri

doi:10.1016/s0140-6736(06)69253-2

Cited by 448 publications

(516 citation statements)

References 72 publications

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“…6 We also included other cases of dilated cardiomyopathy since the presentation and outcomes in patients with cardiomyopathy who present before the last month of gestation are similar to those with peripartum cardiomyopathy. 8 The incidence of cardiomyopathy was highest among the African-American women and women with hypertension. This association is consistent with previous studies, but the literature is unclear if race is an independent risk factor or whether race interacts with hypertension to increase the risk of cardiomyopathy.…”

Section: Discussionmentioning

confidence: 99%

“…6 Previous studies and reviews have focused largely on the medical and obstetric management of these patients. [7][8][9] Literature on anesthetic management has been limited to individual case reports. [10][11][12] The purpose of this case series was to report on the peripartum anesthetic management and outcomes of women with dilated cardiomyopathy in a large university medical centre.…”

Section: Résumémentioning

confidence: 99%

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Anesthetic management and outcomes of parturients with dilated cardiomyopathy in an academic centre

Ituk

Habib

Polin

et al. 2014

Can J Anesth/J Can Anesth

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Purpose This study examines the peripartum anesthetic management and outcomes of women with dilated cardiomyopathy in a large university medical centre over a seven-year period. Principal findings Twenty-five women were included in this series, 18 with a new diagnosis of cardiomyopathy and seven with a history of cardiomyopathy. Sixteen patients (64%) identified themselves as African American, seven (28%) were Caucasian, and two patients (8%) were Hispanic. The median (range) gestational age at the time of a new diagnosis of cardiomyopathy was 29 (7-38) weeks. Eight women (32%) had New York Heart Association class III/IV symptoms at the time of delivery or in the immediate postpartum period. A multidisciplinary team of obstetricians, anesthesiologists, cardiologists, and pediatricians were involved in the care of these women. The median (range) gestational age at the time of delivery was 33.5 (30-40) weeks. There were nine vaginal deliveries and 15 operative deliveries. One patient had fetal loss at 19 weeks gestation. Twelve women had labour induced with an intravenous infusion of oxytocin at a rate of 0.001-0.02 IUÁmin -1 . An oxytocin infusion at a variable rate with a maximum dose of 0.05 IUÁmin -1 was administered after vaginal delivery to maintain uterine tone. Epidural analgesia was initiated prior to induction of labour or in the latent phase of labour. Seven Cesarean deliveries were performed under combined spinal-epidural anesthesia, five were performed under epidural anesthesia, and three women had general anesthesia. Oxytocin was administered via an intravenous infusion at a rate of 0.05-0.2 IUÁmin -1 after operative delivery. One patient had a cardiac arrest on induction of general anesthesia and was successfully resuscitated. There were no maternal or neonatal deaths. Ten women were followed up at our institution and at six months postpartum; 50% of these patients were still symptomatic. Conclusion We report favourable outcomes in 25 pregnant women with dilated cardiomyopathy who were managed by a multidisciplinary team. Résumé

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Section: Discussionmentioning

confidence: 99%

Section: Résumémentioning

confidence: 99%

Anesthetic management and outcomes of parturients with dilated cardiomyopathy in an academic centre

Ituk

Habib

Polin

et al. 2014

Can J Anesth/J Can Anesth

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“…PPCM is observed in 1 of 3,000-4,000 live births [9] and mortality is approximately 15% despite optimal treatment [10]. Preeclampsia is a known risk factor for PPCM [10].…”

Section: Discussionmentioning

confidence: 99%

“…PPCM is observed in 1 of 3,000-4,000 live births [9] and mortality is approximately 15% despite optimal treatment [10]. Preeclampsia is a known risk factor for PPCM [10]. Patients most commonly present with signs and symptoms of systolic heart disease, but with (unnoticed) progression of the disease the heart may dilate and thrombus formation in the ventricles may occur.…”

Section: Discussionmentioning

confidence: 99%

Ischemic neuropathy and rhabdomyolysis as presenting symptoms of postpartum cardiomyopathy

Helmich

Laarhoven

Schoonderwaldt

et al. 2008

J Thromb Thrombolysis

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Rhabdomyolysis and peripheral neuropathy are two distinct disease entities which are rarely encountered in combination. We present a woman with rhabdomyolysis and peripheral neuropathy 3 weeks postpartum. Her symptoms were caused by bilateral femoral artery thrombosis due to postpartum cardiomyopathy (PPCM). This demonstrates that PPCM may present with predominantly non-cardial symptoms and underscores the importance of rapidly recognizing this disorder.Keywords Postpartum cardiomyopathy Á Neuropathy Á Rhabdomyolysis Case reportA 22-year-old woman was referred from another hospital to our department of neurology because of severe rhabdomyolysis (CK levels of [13,000 U/l) and muscle weakness of both legs. Five days before admission she suffered from acute muscle cramps, followed by muscle weakness in both legs and numbness of both feet. Her medical history revealed preeclampsia 1 month earlier and she delivered a healthy baby 3 weeks before presentation. She used folic acid and ferrofumarate because of the recent pregnancy and nitrofurantoine because of a urinary tract infection. She did not smoke and used no alcohol. Neurological examination revealed a paresis of the anterior tibial and extensor hallucis longus muscles on both sides (left [ right). There was sock-shaped hyposensibility without pain. Both feet were warm and had a normal color. The right leg was edematous and arterial pulsations were absent in the right foot. Electromyography showed multiple neuropathies in distal branches of the left peroneal, posterior tibial, sural and superficial peroneal nerves. Muscle biopsy revealed no abnormalities. On angiography of the legs thrombosis of the right internal iliac artery, the right proximal superficial femoral artery (AFS), the left AFS, popliteal and anterior tibial arteries was observed as well as an infarction of the right kidney (Fig. 1). The chest X-ray showed a widened mediastinum and echocardiography revealed a decreased left ventricular function (ejection fraction 30%). No thrombophilic risk factors were found and there was no evidence for an autoimmune disease (normal levels of homocysteine, antithrombin, protein C and S, factor V mutation, prothrombin mutation, lupus anticoagulant, anticardiolipin, ANA, ANCA, complement C3 and C4 all negative). Based on a cardiomyopathy in the context of her recent pregnancy, postpartum cardiomyopathy (PPCM) was diagnosed. Later, when asked for earlier symptoms of cardiomyopathy, the patient mentioned that she had been progressively dyspnoeic in the last weeks of her pregnancy. Thrombectomy of the occluded arteries was performed and anticoagulation (low molecular weight heparin) was started. Thereafter the patient was treated with a vitamin K antagonist, acetylsalicylic acid and an ace-inhibitor. After 8 months the patient had only mild neuropathic pain in her left foot, which responded well to gabapentin. Her heart

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“…9 The recurrence rate of 50-100% 2 is influenced by the severity of PPCM during the index pregnancy and by left ventricular systolic function at the beginning of pregnancy. 10 Echocardiography may be helpful in delineating future risk in patients considering future pregnancies. 2 Long-term prognosis is related to recovery of left ventricular function with 80% of women recovering partially or completely, and the remaining 20% either dying or undergo cardiac transplantation.…”

mentioning

confidence: 99%

The peripartum anesthesiologist

Munro

George

2014

Can J Anesth/J Can Anesth

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The association between pregnancy and cardiomyopathy has been evident since 1870. 1 Moreover, the incidence of peripartum cardiomyopathy (PPCM) is thought to range from 1 in 2,400 to 1 in 15,000 pregnancies; 2 however, a more recent review suggests an incidence of one in 3,000 to 4,000 pregnancies in western countries. 3 Peripartum cardiomyopathy is more prevalent in older multiparous patients of African descent who have multiple gestations, chronic hypertension or preeclampsia, and have received prolonged tocolytic therapy. 2,4 There are four principal diagnostic features of PPCM: the development of heart failure in the last month of pregnancy or within five months of delivery; absence of an identifiable cause; absence of underlying heart disease prior to the last month of pregnancy; and evidence of left ventricular systolic dysfunction. 5 Recently, echocardiographic criteria were established, including an ejection fraction \ 45% and an end-diastolic dimension [ 2.72 cmÁm -2 . 6 Basic principal treatment of PPCM includes a reduction of both preload and afterload along with the administration of inotropic therapy. Severe cases may require mechanical support and consideration for heart transplantation. 3,4 Delivery of the fetus is usually indicated when the cardiac failure is intractable. 3 In this month's edition of the Journal, Ituk et al. 7 report on the peripartum anesthetic management and outcomes of 25 women with dilated cardiomyopathy -four of whom were designated as having PPCM. With an average age of 32 and a history of hypertension and diabetes, these patients represent a higher risk group than the overall obstetrical population, which is in keeping with previous reports of PPCM risk factors. 5 This challenging group of patients was optimally managed by a multidisciplinary team with a distinct knowledge of peripartum care -a team that followed their patients' clinical progress at regular multidisciplinary case conferences.Fetal delivery in PPCM is dictated by the obstetric indications and occurs in consultation with the anesthesia team. Vaginal delivery offers minimal blood loss, hemodynamic stability, and avoidance of additional Cesarean delivery-related surgical stresses with an overall reduced chance of postoperative complications. Regional anesthesia is advantageous for reducing preload and afterload and minimizing the fluctuations in cardiac output associated with labour. Cesarean delivery is best reserved for indications such as breech presentation, fetal distress, or failure to progress. 8 Prognostic information of PPCM is limited and often confounded by the inclusion of patients with heart failure of differing etiologies. The reported mortality ranges from 18-50% 2 and it increases as a function of age, ejection fraction \ 25%, multiparity, African American ethnicity, and delayed diagnosis. 9 The recurrence rate of 50-100% 2 is influenced by the severity of PPCM during the index pregnancy and by left ventricular systolic function at the beginning of pregnancy. 10 Echocardiography may be helpful ...

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Peripartum cardiomyopathy

Cited by 448 publications

References 72 publications

Anesthetic management and outcomes of parturients with dilated cardiomyopathy in an academic centre

Anesthetic management and outcomes of parturients with dilated cardiomyopathy in an academic centre

Ischemic neuropathy and rhabdomyolysis as presenting symptoms of postpartum cardiomyopathy

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