ß πºÿâªé«: «â π ÈÕÀ «º ª µ À«à ßµ Èß å À ÕÀ ß Õ A case report : Peripartum cardiomy opathy
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- Caroline Hamilton
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1 «ß πºÿâªé«: «â π ÈÕÀ «º ª µ À«à ßµ Èß å À ÕÀ ß Õ A case report : Peripartum cardiomy opathy Õ ÈÕæß»å ªæπ * Uaepong Limpapasit* àõ «â π ÈÕÀ «º ª µ À«à ßµ Èß åà ÕÀ ß Õ Peripartum cardiomyopathy ªìπ «Ëæ â à àõ Õÿ µ åª µàõ 100,000 Õ π à«ß 1 Õπ àõπ Õ ß 5 ÕπÀ ß Õ ªí ÿ π ß à Àµÿ Ë π µ «Õ à ß π» π È Õ ÿ 20 ªï µ Èß å âõß Õ ÿ å 33 ª Àå ºπ ºŸâªÉ«π ßæ À â««severe pre-eclampsia â ºà µ Õ À ß ºà µ â 3 «π ºŸâªÉ«Ë Õ Àπ ËÕ ÀÕ πõπ à â µ «à ß Õ åªõ æ «À «â À «µ «ËπÀ «cardiac enzyme àæ «acute myocardial infarction µ «Echocardiogram æ dilated cardiomyopathy with (LVEF) âõ 49 with global hypokinesia ß â «π «à Peripartum cardiomyopathy À ß â Àâ ªí «Õ ºŸâªÉ«Èπ â π â π Ë ÿ Ë«ª ËßÀπ Ëß ÕߺŸâªÉ«Ë ªìπ π ÈÕ Èπ π à LVEF π Ÿàª µ µà æ «à ºŸâªÉ«Àπ Ëß π Õ ªìπ È π µ Èß å Èß ª ßπ Èπ Ëß Ë ÿ À ºŸâªÉ«Ë «π È Õ «π π ÿ π Àâ àºÿâªé«ÿ : «â π ÈÕÀ «º ª µ À«à ßµ Èß å, ßæ À. *Õ ÿ ßæ À 152
2 Abstract Peripartum cardiomyopathy was uncommon condition. The incidence was about per 100,000 births. This condition usually occurs in from 1 month before to 5 months after delivery. The obvious cause is not well defined. This case study was a 20 years old female patient with 33 th weeks gestational age first pregnancy, who was admitted to Mahasarakham hospital because of severe pre-eclampsia. Three day after treated by cesarean section, she began having dyspnea, her physical examination and chest x-ray showed congestive heart failure. Electrocardiogram and cardiac enzymes not encountered with acute myocardial infarction. Echocardiogram showed dilated cardiomyopathy with LVEF 49% with global hypokinesia. Finally she was diagnosed with Peripartum cardiomyopathy. After treatment by a diuretic drug, her symptoms improved and she could go home at the end. In general, about half of patients with this disease, their LVEF will return to normal. However approximately one third of patients will suffer from recurrent disease in the next pregnancy. Therefore, the most important thing for patients with this condition is that we should recommend contraception for all patients. Keywords : Peripartum Cardiomyopathy, Mahasarakham Hospital MAHASARAKHAM HOSPITAL JOURNAL Vol. 11 No. 2 June
3 π Peripartum cardiomyopathy À Õ pregnancy-associated cardiomyopathy ªìπ «Ëæ â à àõ µà «ß π π ËÕß «π â â À Õ à «π âõ àõ Àâ «Õ πµ ß «µ Õß â «π È π à«ß 1 Õπ àõπ Õ ß 5 ÕπÀ ß Õ 1,2 Õÿ µ åæ ⪠µàõ 100,000 Õ 2 ªí ÿ π ß à Àµÿ Ë π «π µâõßõ» µ Àπ ß «π È πºÿâªé«à«ß â Õ À ÕÀ ß Õ Ë â«õ À «â À «â««π Õ ËπÕÕ ª àõπ ßπ Èπ «Ÿâ «â À Õ ª å π Ÿ ºŸâªÉ«Ëà ªìπ Peripartum cardiomyopathy ß ª πå π ºŸâªÉ«æ ËÕ À⺟âªÉ«â Ë Ÿ µâõß Õ à ß π à«ß ß ºŸâªÉ«: ºŸâªÉ«À ß Ÿà π æ Õ ÿ 20 ªï ßµ Èß å (G1P0) Õ ÿ å 33 ª Àå â«õ Õß â ß «Èπ ª 7 «π à Õ Àπ ËÕ ÀÕ ªí «ª µ πõπ â à Á Àπâ Õ «ππ È ªæ æ å Ë π ««π À µ â 155/ 92 mmhg à Õ ª à µ æ à «à ÿ πàπ µâ Èπªïò Á Èπª µ ß â πõπ ßæ Past History : à ª µ «à µ «Õ «π À µ Ÿß àõπ - à«ßω å àõπàπâ π Ȫ µ µ Õ - ªØ ⪠ªØ æâ - ªØ Ÿ ÿà ËÀ Õ Ë ÿ - ª π â «Àπ «Õ ÿ ÈÕ ªØ ª π πª â À Õ ÕßÀ Õß - ºà µ âµ Ëß ªï 2542 à «âõπ - «π µ Àπ Family History : ªìπ À«π «π À µ Ÿß - à π π Õ «ªìπ À «- à π π Õ «ªìπ «π À µ Ÿß µ Èß å Physical examination : - Vital signs: Body temperature (BT) 36.9 ÌC, Pulse rate (PR) 108/min, Respiratory rate (RR) 20/min, Blood pressure (BP) 158/103 mmhg HEENT : not pale, no jaundice, no neck vein engorgement Heart : apical beat at Left 5 th ICS, mid clavicular line, normal S1S2, no murmur Lung: equal breath sound, no adventitious sound Abdomen : soft, not tender, no hepatosplenomegaly, fundal height 3 / 4 above umbilicus, FHR 142/min Extremities : pitting edema 2+ Neurological signs : Intact Per Vagina examination : os closed Lab: - Urinalysis: specific gravity 1.025, protein 4+, glucose negative, ketone negative, RBC 0-1 cell/mm 3, WBC 2-3 cell/mm 3 - Urine 24 hr protein 3764 mg/day CBC : Hb 11.3 g/dl, Hct 32.1%, WBC 9740/mm 3 (Neutrophil 72%, Lymphocyte 25%), Platelet 322,000/mm 3 Blood chemistry: BUN 6 mg/dl, Cr 0.5 mg/dl, Na 137 meq/l, K 3.1 meq/l, Cl 103 meq/l, HCO3 22 meq/l LFT: Alb 2.6 g/dl, Glb 2.6 g/dl, TB 0.4 mg/dl, DB 0.2 mg/dl, ALT 8 U/L, AST 18 U/L, ALP 191 U/L Anti-HIV negative, HBsAg negative, Anti-HBs negative, Anti-HCV negative EKG 12 lead: normal sinus rhythm, rate 100/min Hospital course: â admit ÀâÕß Õ Ÿµ æ å ª π Õ Àâ «π «à ªìπ G1P0, GA 33 wk with severe pre-eclampsia â Ë Àâ Àâ Dexamethasone 4 mg intravenous (IV) q12hr x 4 doses, 10% MgSO4 4 gm IV slow push then 50% MgSO4 10 gm + 5%DW 1000 ml IV 100 ml/hr, monitor fetal heart, NPO Intake/output 900/500 ml æ Ë π Àâ 50% MgSO4 20 gm + 5% DW 1000 ml IV 75 ml/hr, Acetar 1000 ml IV 35 ml/hr x ª ÿ æ å ª π mild degree of hypertensive retinopathy Intake/output 3430/2900 ml 154
4 â 50% Mg SO4 20 gm + 5% DW 1000 ml IV 75 ml/hr, Acetar 1000 ml IV 35 ml/hr Ÿµ æ å âºà µ cesarean section π ÈπÀ ßºà µ â Àâ πè ªìπ 5%DN/2 1000ml + syntocinon 20 unit IV 60 ml/hr 2 «, 5%DN/ ml IV 120 ml/hr 1 «, 50% Mg SO4 20 gm + 5%DW 500 ml IV drip 50 ml/hr x 24 hr Intake/ output 2840/2550 ml (estimated blood loss À«à ßºà µ 300 ml) âà ÿ πè À ß À «Ë Àâ πõ À Intake/output 2460/2000 ml à â record Intake/output à â record Intake/output Ë Õ Àπ ËÕ ÀÕ πõπ à â Õ À à â BP 167/103 mmhg, HR 110/min, RR 24/min, BT 37.6 ÌC, HEENT: not pale, neck vein engorgement, Heart: apical beat at Left 6th ICS, 1 FB lateral to mid clavicular line, normal S1S2, no murmur, Lung: fine crepitation both lungs, Abdomen: soft, no hepatosplenomegaly, Ext: pitting edema 2+ EKG : sinus tachycardia, rate 100, nonspecific inverted T in V1-2 Chest x-ray: cardiomegaly with cephalization with bilateral pleural effusion ß Ÿª Lab: CBC: WBC 15650/mm3(Neutrophil 90%, Lymphocyte 8%), Hb 12 g/dl, Hct 36%, Platelet /mm3, BUN 10 mg/dl, Cr 0.6 mgdl, Na 141 meq/l, K 3.6 meq/l, Cl 102 meq/l, HCO3 22 meq/l, serial Troponin T < 50 ng/l Èß Õß Èß «π Congestive heart failure â â ICU Õ ÿ on O2 mask with bag, Nitroglycerine IV drip, furosemide 40 mg IV q6hr, Elixir KCL 30 ml oral 2 doses Intake/output 380/1735 ml Õ Àπ ËÕ ß crepitation ß À ß â ªí «â æ Ë Enalapril (5) 1/2 tab oral bid Echocardiogram: dilated cardiomyopathy with mild MR, mild AR with LVEF 49% with global hypokinesia Intake/ output 1127/5260 ml à Àπ ËÕ â«πõπ â µ «lung: no crepitation â ºŸâªÉ«ªµ Õ ÿ À ß ª furosemide (40) 1 tab oral pc OD Õ ª µ â â π Chest x-ray àõπ â π ªìπ ß Ÿª MAHASARAKHAM HOSPITAL JOURNAL Vol. 11 No. 2 June
5 «å ºŸâªÉ«π È πõπ ßæ â«g1p0, GA 33 wk with severe pre-eclampsia â â«mgso4 IV â ºà âõß Õ À ß â steroid 48 Ë«ß Õ À ßºà µ à«ß Õ Ÿà π ±åª µ µà π«π Ë 4 À ßºà µ â «congestive heart failure Èπ âõπ Ëß πºÿâªé«π È Õ «congestive heart failure â À Àµÿ ßπ È 3,4 1. Peripartum cardiomyopathy ªìπ Àµÿ Õß «À «â À «πà ßµ Èß å Ë à ªìπ À «àõπ æ âµ Èß µà à«ßª Õß µ Èß å π ß à«ßµâπà ß Õ ÿµ àπ π ºŸâªÉ«ªí Ë ß Õ «pre-eclampsia º echo æ LV systolic dysfunction µ ««Àå æ Ë µ àæ ÀµÿÕ Ëπ Õß «À «â À «Ëß â â Õ ÕߺŸâªÉ«π È Ë ÿ 2. Pre-existing unrecognized idiopathic dilated cardiomyopathy Õ ªìπ «π È â ºŸâªÉ«Õ ªìπ mild degree DCM Õ Ÿà â«ÿ µÿâπ æ «Õß µ Èß å à«volume overload IV fluid µà «Õ µ Èß µà µ Ë Õß Õß µ Èß å «à Õ à ß Áµ ßµâÕß â µ µ LVEF À ß Õ «à ªìπª µ À Õ à Ëß «π È LVEF à Ÿà à ª µ 3. Pre-existing unrecognized congenital heart disease/valvular heart disease ßπâÕ π ËÕß «Õ µ Èß µà µ Ë Õß Õß µ Èß å «à µ «à ß ß À «ª µ º Echo à Õ âõß 4. Pre-eclampsia or pre-existing hypertensive heart disease ºŸâªÉ«ªí À «π À µ àõπ â ß Ÿßµ Èß µà πõπ ßæ µà ß à ß Õß hypertensive crisis ºŸâªÉ«ÿà π È à «µ «æ ß Õß LVEF 5. Pregnancy associated myocardial infarction ºŸâªÉ«à Õ Á πàπàπâ Õ µ «EKG æ nonspecific inverted T wave in V1-2 µà serial Troponin T Õß Èß Àà ß π 6. º <50 ng/l ß ß à À π π πÿπ «π «π È Õ Õ ß º µ «ßÀâÕß ªØ µ πºÿâªé«π È ÿª â«à â â «peripartum cardiomyopathy Ë ÿ ËÕ â â«ªí ««ÿ «π À µ ÀâÕ Ÿà π ±åª µ æ «à Õ ÕߺŸâªÉ«Èπ â π â Peripartum Cardiomyopathy Õ ËÕÀπ Ëß«à pregnancy-associated cardiomyopathy ªìπ Àµÿ «À «â À «Ëæ â à àõ π à«ß 1 Õπ àõπ Õ ß 5 ÕπÀ ß Õ 1,2 Õÿ µ åæ ª µàõ 100,000 Õ 2 ªìπ Ë ß à Àµÿ Ë π ËÕ«à Õ Abnormal immune process, cardiotropic viral infection, À Õ abnormal response to prolactin 2,5,6 ªí Ë ß Ë Ë «âõß â à 1,2,6,8 1. Õ ÿµõπµ Èß å Ë «à 30 ªï 2. Multiparity 3. Pregnancy with multiple fetuses 4. Pregnancy-induced hypertension 5. Cocaine abuse 6. Long term oral tocolytic with beta agonist >4 ª Àå Õ Õ ß Õß Peripartum Cardiomyopathy à µ µà ß Õ À «â À «ÀµÿÕ Ëπ Õ Ëæ àõ Ë ÿ ÕÕ Àπ ËÕ ÀÕ Õ Õ ËπÊ Ëæ â Õ Õ Õ PND orthopnea «1,2,5 Õ À «â À «À ßÕ ÿ å 36 ª Àå µ µà ß ºŸâªÉ«Ë À «àõπµ Èß å Ë Õ À «â À «µ Èß µà µ Ë Õß Õß µ Èß å «π «π È ªìπ «π Õ Ëπ ÕÕ ª àõπ (Diagnosis by exclusion) ±å π «π ËßµâÕß ÿ âõ ßµàÕ ªπ È1,2 1. Õ À «â À «Èπ À«à ß 1 Õπ ÿ â Õß µ Èß å ß 5 ÕπÀ ß Õ 2. àæ «à ÀµÿÕ Ëπ Ë Àâ Õ À «â À «3. à µ «Õ«à ªìπ À «àõπàπâ 1 Õπ ÿ â Õß µ Èß å 4. º Echocardiogram æ LV systolic dysfunction (LVEF < 45 or reduced shortening fraction) 156
6 àßµ «ßÀâÕßªØ µ 1. EKG à ª Ë π ª ß Ë æ Õ æ sinus tachycardia, non-specific ST-T change, low voltage or LVH, Q in anterior precordial leads 2. Chest X-ray æ cardiomegaly with pulmonary venous congestion 3. Echocardiogram æ global hypokinesia, LV enlargement without hypertrophy, LVEF < 45% or fractional shortening < 30%, LV end-systolic dimension > 2.7 cm/m 2 Õ Ëπ Ëæ â Õ mitral and tricuspid regurgitation, Left atrial enlargement, small pericardial effusion 4. NT-proBNP æ à Ÿß Èπ «à ºŸâÀ ßµ Èß å ª µ ª 5 à 2,5 5. Coronary angiography Õ æ π Ë ªí Ë ß À «Õ À à µ µà ß πºÿâªé«à «â À «ÀµÿÕ Ëπ 1,2,5 â à 1. Ÿ à«à ÕÕ π 2. Àâ ªí «æ ËÕ preload 3. Àâ «π À µ Ë à º µàõ Á π å æ ËÕ afterload π Ë «π À µ Ÿß àπ hydralazine, nitrate 4. Àâ ÿà inotropic drugs π Ëæ «à cardiac output µë 5. Õ â Õ À «â À «ÿπ ß 6. Ÿ π «À ß Õ àπ πè Õ ÕÕ ß Àπ ß Àâ π ÿµ Àâ µ π π ºŸâªÉ«systolic heart failure àπ ACEI, Beta-blocker, spinorolactone 7. µ «µ µ echocardiogram Ë 6 ª Àå 6 Õπ 12 Õπ π Èπ ÿ 1 ªï æ ËÕª πº «π Ë πà ß à ÿ «â π µà π π Àâ ß â«µ π π ºŸâªÉ«systolic heart failure µàõ ªÕ Õ à ßπâÕ 12 Õπ Àâ ªµ Õ «µ â LVEF à Ÿàª µ Ë 12 Õπ 2,7 æ å π Èπæ «à ËßÀπ Ëß ÕߺŸâªÉ«à LVEF ª µ æ ºŸâªÉ«Ë à LVEF > 30% πµõπ«π ºŸâªÉ«Õ ÿ Ë LVEF Èπ π 6 Õπ Õ µ µ Ë 2 ªï à 10% â «à Õ ªìπª µ µàæ «à ºŸâªÉ«Àπ Ëß π ªìπ È π µ Èß å Èß ª ßπ Èπ ß «π π ÿ π Àâ àºÿâªé«ÿ 1 ÿª-õ ª º ß πºÿâªé«peripartum cardiomyopathy ªìπ «Ëæ â à àõ µà «æ «π Ë â à π å àߺ Àâ «âõπ ß Èπ «µ â ΩÑ «ß π Ë «Ë ß àõπ «ß à «ß ªìπ«Ë Ë ÿ ß» π È ËºŸâªÉ««Ë ß Õ «severe pre-eclampsia π àõπ Ëß ««À πß π«meta-analysis æ «à Ë pre-eclampsia Èπ ª 5% πºÿâà ßµ Èß å Ë«ª µà πºÿâà ßµ Èß å Ë peripartum cardiomyopathy à«â«æ preeclampsia â ß 22% 9 πõ π ȺŸâªÉ«Ë «severe pre-eclampsia À Õ eclampsia â Àâ πè πª Ë «à ºŸâÀ ßµ Èß å Ë«ª àπ â MgSO4 IV, Syntocinon IV æ Ë µ Àâ æ Ë «Ë ß π «πè π heart failure µ âßà ÈπÕ ßπ Èπ Ÿ ºŸâªÉ«µ Èß å Ë ßæ â«severe pre-eclampsia À Õ eclampsia æ ËÕÀ Ë ßÀ Õ «ÿπ ß Õß «peripartum cardiomyopathy ß «ª Õ â«µ ßµàÕ ªπ È 1. ª πè Ë Àâ ß âπ Õ à π ml/hr π à«ß 24 Ë«ß àõπ À ß Õ 2. æ Ë «â âπ Õß MgSO4, Syntocinon À Õ Õ ËπÊ Ë Àâ ß âπ Õ æ ËÕ ª πè Ë Àâ ß 3. µ µ «æ ª ªí «Õ à ß â µ Èß µà à«ß àõπ Õ π Ëß 72 Ë«ßÀ ß Õ «ÿ «π À µ ÀâπâÕ «à 150/100 mmhg 4. Àâ Ÿ µ π«ßªø µ Õß Pregnancy induced hypertension 10,11 â Ë ÿ «Ÿâ «â πµ «ª å π «µ Àπ ß «peripartum cardiomyopathy π æ ºŸâªÉ«Ë «Ë ß à«àâ «π ªìπ ª â«««á«àߺ À⺟âªÉ«ª Õ Ëß Èπ MAHASARAKHAM HOSPITAL JOURNAL Vol. 11 No. 2 June
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