Peripartum kardiomyopati

Transcription

1 Fall 3 Peripartum kardiomyopati Roman A roch

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4 Dg. PPCM Symptoms ECG, pro-bnp echocardiography 4

5 Peripartum cardiomyopathy: a systematic literature review Acta Obstetricia et Gynecologica Scandinavica Volume 95, Issue 11, pages , 19 OCT 2016 DOI: /aogs

6 Incidence PPCM USA: 1/ birth South Africa:1/1000 Haiti:1/299 Last month<->5month postpartum 6

7 Examination Mostly the same as in non-pregnant patient Careful history, family history Physical exam Biomarkers (in complicated pregnancy) not validated ECG, maybe Holter Echocardiography serial examinations structure, function, pulmonary hypertension, etc. exercise testing? Limit radiation exposure MR probably safe after 1 st trimester Biopsy-no 7

8 Diff Dg Mitral valve stenosis Preeclampsia/eclampsia HT CHD Other CM 8

9 Diff Dg 9

10 Riskfactors multiparity multifetal pregnancies older maternal age pregnancy induced hypertension or preeclampsia prolonged use of tocolysis 10

11 Etiology/hypothesis nutritional deficiencies, genetic disorders viral or autoimmune causes, hormonal imbalances, volume overload of pregnancy, alcohol, physiologic stress of pregnancy, abnormal immune response to pregnancy, unmasking of latent idiopathic dilated cardiomyopathy, inflammation, Apoptosis (none proven..) 11

12 Etiology/hypothesis proteolytic cleavage of prolactin into its detrimental 16kDa form producing endothelial cell apoptosis, capillary dissociation, and vasoconstriction ( can be blocked by bromocriptin= proven in mice.and 20 patients) 12

13 Peripartum cardiomyopathy: a systematic literature review Acta Obstetricia et Gynecologica Scandinavica Volume 95, Issue 11, pages , 19 OCT 2016 DOI: /aogs

14 Treatment strategy Bromocriptine blocking of enhanced cleavage of the nursing hormone PRL into a deleterious, antiangiogenic and proapoptotic form Delivery<->cesaren section Stop lactation (mechanicaly,pravidel) 14

15 Treatment strategy diuretics angiotensin-converting enzyme-inhibitors angiotensin receptor antagonists (oligohydramnios, renal failure, death, miscarriage or uterine fetal death, respiratory distress syndrome.) β blockers (born small for gestational age, preterm birth, and perinatal mortality) aldosterone antagonists, intravenous and oral vasodilatators, intravenous inotropes Anticoagulation ifef<35% Cardiogenic shock(iabp,ecmo,lvad,transplant) 15

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17 Planning the delivery: individualized Timing Induction Vaginal vs. caesarean delivery usually vaginal if possible, as long as there are not obstetrical contraindications Hemodynamic monitoring, specific treatment Anesthesia/analgesia good labor analgesia- epidural If caesarean section planned, consider combined spinal and epidural anesthetic 36

18 Prognosis 23-78% in 5 years good recovery 1,4-30% mortality Better prognosis than DCM 18

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20 Preeclampsia<->PPCM 20

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22 Prognosis Mortality due to PPCM usually occurs in the first 6 months postpartum, and is often due to ventricular arrhythmias, progressive heart failure, or thromboembolic complications. 22

23 Subsequent pregnancy 23

24 Summary Cardiomyopathy in pregnancy is a potentially life-threatening illness which poses great treatment challenges This is common enough that most of us will be involved in treating such a patient Cardiomyopathies in pregnant women can take different forms, have different pathophysiological implications for our management 24

25 Conclusions Treatment and planning for these patients is best undertaken in multidisciplinary teams Obstetrician Cardiologist Intensivist and anesthesiologist Others if needed 54

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38 PLEURAVÄTSKA 42% 90% SENSITET SPECIFICITET SENSITET SPECIFICITET 39% 85% SENSITET SPECIFICITET 92% 93% INFILTRAT (alveolar consolidation) 8% 100% 68% 95% 93% 100% ÖKAD INTERSTITIELL VÄTSKA (alvoelarinterstitial syndrome) 34% 90% 60% 100% 98% 88% Anesthesiology 2004; 100:9 15

39 Take home message - Remiss med viss frågeställning behöver inte spegla den egentliga problem - Alla gravida är andfådda och svårt undersökta - Systematisk undersökning av hjärtat och runt hjälper - Nytta av septumrörelse mönster