MANAGEMENT OF A CASE OF PERIPARTUM DILATED CARDIOMYOPATHY
POST- EMERGENCY LSCS
BACKGROUND
:
Peripartum cardiomyopathy is defined as the onset of acute heart failure without demonstrable
cause in the last trimester of pregnancy or within the first 6 months after delivery.
We are
reporting a case of peripartum cardiomyopathy,after emergency caesarean section developed
ventricular arrhythmias and cardiac arrest during surgery.
CASE PRESENTATION :
A 25-yr old female , primigravida, at 36weeks of gestation, an un-booked case , presented to the
labour room with history of seizures and 1 episode of vomiting since 3hrs. On Pre-anesthetic
evaluation : Patient was irritable and semi-conscious. pulse:110/minute, blood
pressure:190/110 mm of Hg, SPO2 : 57% with 8litres of oxygen, cardiovascular system: s1
,s2 heard,no murmurs, respiratory system: bilateral crepitations present, per abdomen: term
size uterus, ECG showed no significant changes. Patient pre-medicated with Inj.glycopyrolate
0.2mg/iv, Inj.Ondansetron 4mg/iv,Inj.Fentanyl 100mcg/iv, pre-oxygenated with 6ltrs
Oxygen.Rapid sequence induction done with Inj.Propofol 100mg/iv. Intubation was
facilitated by Inj.SuccinylCholine 100mg intravenously and intubated orally by direct
laryngoscopy with 7.5mm size cuffed Endotracheal tube. Soon after intubation Patient
developed asystole. Chest compressions started in left lateral position.Inj.Adrenaline 1mg/iv given.
Patient developed ventricular tachycardia with a rate of 140/minute and was administered
preservative free injection xylocaine 80mg/iv given. The ventricular tachycardia did not revert even
after administration of additional 80 mg dose of xylocaine and progressed to ventricular fibrillation.
Cardioversion done with 200Joules and CPR continued. . Cardiac activity and sinus rhythm regained.
Anaesthesia was maintained with 100% O2 and Inj.Atracurium 25mg/iv. Monitored with
pulseoxymetry,ECG,ETCO2,temperature and Non-invasive Blood pressures Intra-op BP were
70/40 and SPO2 90% with 100% Oxygen. Ionotropes Inj.Dopamine 20mcg/kg/min and
Inj.Dobutamine 10mcg/kg/min started .Rest of the surgery was uneventful and still born baby was
delivered . After the surgery, patient was shifted to Intensive Care Unit (ICU) for Ventillatory care.
Patient was advised Chest X-ray and Echocardiography. X-ray chest showed cardiomegaly with a
pneumonic patch in the left middle lobe of the lung but ECHO showed dilated cardiomyopathy with
a severe LV dysfunction with ejection fraction of 19% ,moderate Eccentric MR. Rapid Digitalization
done with inj digoxin 500mcg intravenously with in 24hours. Patient given trial extubated after
24hrs , 7 hrs after extubation ,patient developed severe respiratory distress and was again reintubated and connected to mechanical ventilator, patient completely paralysed and put on
controlled ventilation. Patient was ventilated for a period of 20 days and during which she
developed 2 episodes of Transient Ventricular Tachycardia, which was treated with Inj.Amiodarone
150mg given over a period of 10mins.patient underwent tracheostomy on the 11th post-op day and
extubated on the 20th post-op day after the pneumonic patch has resolved and patient was doing
well.
CONCLUSION:
Peripartum cardiomyopathy occurs in about 1 in 4000 deliveries and is often
unrecognized, as symptoms of normal pregnancy commonly mimic those of mild heart failure
and is usually diagnosed in the post partum period by ECHOCARDIOGRAM .Morbidity and
mortality varies from 7%-50%.
discharged and patient doing well
We are reporting a case which was successfully managed and