Peripartum cardiomyopathy and thromboembolism; anesthetic management and clinical course of an obese, diabetic patient

Abstract

P Pu ur rp po os se e: : To describe the anesthetic management and clinical course of a patient with peripartum cardiomyopathy. We highlight the frequent occurrence of thromboembolic morbidity in this group of parturients, emphasizing the need for early consideration of prophylactic anticoagulation.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : A 38-yr-old, diabetic, obese parturient was admitted with pulmonary edema and severe orthopnea at 31 weeks gestation. The respiratory rate was 44 breaths·min and rales were heard in both lung fields. The diagnosis of peripartum cardiomyopathy was made based on sinus tachycardia with no evidence of ischemia on the electrocardiogram, and global left ventricular hypokinesis with an ejection fraction of 40-45% noted on transthoracic echocardiography. Cesarean delivery was planned to improve maternal respiratory status and hemodynamics. General anesthesia with invasive monitoring was planned, and surgery and anesthesia proceeded uneventfully. Less than 24 hr postoperatively, she sustained a thrombotic cerebral infarct leaving her hemiparetic and dysarthric. Subsequent investigations revealed a thrombophilic state due to elevated anticardiolipin antibody.C Co on nc cl lu us si io on n: : General anesthesia is an acceptable option in parturients with heart failure secondary to cardiomyopathy. Thromboembolic complications are common, and early consideration should be given to prophylactic anticoagulation. Objectif

Peripartum cardiomyopathy: A comprehensive review

“…These observations were noted before initiation of mandatory bed rest, which was the standard of care in the past [11,107], but even more recent reports continue to describe very serious thromboembolic events associated with PPCM, including coronary emboli [125], biventricular thrombi [126][127][128], pulmonary embolism [129], peripheral embolization [130], and thrombotic cerebral infarct [131]. Therefore, anticoagulation with subcutaneous heparin (i.e., 5000 U heparin subcutaneously twice daily) should be strongly considered in this population.…”

Neglected cardiomyopathies in Africa

“…(86) Ventricular thrombosis is common ( Figure 3) and has been reported in up to 53% of patients with peripartum cardiomyopathy. (76,87) Recent thrombi are more shaggy and irregular in confi guration, whereas organised thrombi are more circumscribed and immobile. (88) Some evidence exists for the usefulness of MRI for diagnosis, pathogenic and prognostic consideration in patients with PPCM.…”

“…(78,84,87) The current management of this condition consists of medical therapy using inotropic support, diuretics, beta-blockers, vasodilators (angiotensinconverting enzyme inhibitors, nitrates or hydralazine) and anticoagulants. Although there is currently no consensus as to whether patients with depressed left ventricular function and sinus rhythm should be anticoagulated to prevent thrombus formation, PPCM presents a higher risk and might need aggressive and pre-emptive coagulation once the diagnosis is made.…”

Peripartum Cardiomyopathy

“…Alcuni studi hanno evidenziato un'elevata incidenza di tromboembolia in questa popolazione di donne, comprese embolie coronariche [125], trombi biventricolari [126][127][128], embolie polmonari [129] e periferiche [130] ed infarti cerebrali su base trombotica [131]. Tutto ciò porrebbe indicazione all'utilizzo di eparina a basso peso molecolare (5000 UI 2 volte/die) mentre l'uso di dicumarolici dovrebbe essere evitato per il loro già dimostrato effetto teratogeno [132].…”