June 21, 2012 Balderama-Mendieta

1. June 21, 2012 Balderama-Mendieta

2. OBJECTIVES • Identify pertinent findings from the history and physical examination that would contribute to the diagnosis of peripartumcardiomyopathy • Provide a systematic approach in diagnosing patients with peripartumcardiomyopathy • Determine supportive diagnostic examinations • Arrive at a definitive diagnosis • Learn how to conservatively manage patients with peripartumcardiomyopathy

3. Patient Profile • JT • 32 year-old , Female • Single, Filipino, Roman Catholic • From Quezon City • Admitted for the 1st time at our institution on November 30, 2011

4. Patient Profile • Merchandiser • Denies intake of alcoholic beverages • Denies smoking and taking illicit drugs

5. Patient Profile • Rents the 1st floor of a 4-storey studio type apartment • Sufficient source of water and electricity in the neighbourhood • Garbage collected twice a week

6. Chief Complaint • Difficulty of breathing of 6 days duration Source and Reliability • The patient herself with fair (70%) reliability

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13. Past Medical History • Unremarkable

14. Maternal History • Menstrual History • Menarche at 16 y/o, regular, 28-day cycle, 3 days duration, moderately soaked, 3 pads per day, no dysmenorrhea • Obstetrical History: G2P1 (1011) • G1- 2004, Spontaneous abortion • G2- 2011, LFT male via NSD, delivered at a lying-in-clinic by a mid-wife, the patient had regular pre-natal check-up

15. Gynecologic History • History of pelvic infection, UTI at 16 3/7 weeks AOG of G2 (treated with Cefuroxime 500 mg/tab BID, resolved) • Sexual History • Coitarche at 23 y/o, 2 SP, no post coital bleeding or dyspareunia • Contraceptives History • None

16. Family History • Hypertension, CVD, and asthma – paternal and maternal sides

17. Review of Systems

18. Review of Systems

19. Review of Systems

20. PHYSICAL EXAMINATION

21. Admitting Physical Examination

22. Admitting Physical Examination

23. Admitting Physical Examination

24. Admitting Physical Examination

25. Admitting Physical Examination

26. SALIENT FEATURES

27. Salient Features • 32-year-old female • Recently delivered a full term baby boy • Difficulty of breathing • Orthopnea • Paroxysmal nocturnal dyspnea • Easy fatigability • Bipedal edema

28. Salient Features • In cardiorespiratory distress • BP 130/90; HR 109bpm; RR 34 bpm • BMI: 19.5 • Distended neck veins • Dullness noted on both lower lung fields • Decrease vocal fremitus on both lateral fields Euthyroid In cardiorespiratory distress BP 130/90; HR 109bpm; RR 25bpm BMI: 19.5 Distended neck veins Subcostal retractions Dullness noted on both lower lung fields

29. Salient Features • Decrease breath sounds on both lower lung field • Noted with bibasalcrackles • Tachycardic • Irregular rhythm • Grade 2 bipedal edema Euthyroid In cardiorespiratory distress BP 130/90; HR 109bpm; RR 25bpm BMI: 19.5 Distended neck veins Subcostal retractions Dullness noted on both lower lung fields

30. ADMITTINGIMPRESSION

31. Congestive heart failure probably secondary to peripartum cardiomyopathy r/o pneumonia, severe pre-eclampsia

32. CASE DISCUSSION

33. Harrisons 18th ed.

34. Salient features of: • 32-year-old female • Recently delivered a full term baby boy • Difficulty of breathing • Orthopnea • Paroxysmal nocturnal dyspnea • Easy fatigability • Bipedal edema

35. Salient features of: • In cardiorespiratory distress • Distended neck veins • Dullness noted on both lower lung fields • Decrease vocal fremitus on both lateral fields

36. Salient features of: • Decrease breath sounds on both lower lung field • Noted with bibasal crackles • Tachycardic • Irregular rhythm • Grade 2 bipedal edema :

37. Chest Xray of:

38. Framingham Criteria of: MAJOR • Paroxysmal nocturnal dyspnea • Neck vein distention • Rales • Radiographic cardiomegaly • Acute pulmonary edema • S3 gallop • Increased central venous pressure (>16 cm H2O at right atrium) • Hepatojugularreflux • Weight loss >4.5 kg in 5 days in response to treatment MINOR • Bilateral ankle edema • Nocturnal cough • Dyspnea on ordinary exertion • Hepatomegaly • Pleural effusion • Decrease in vital capacity by one third from maximum recorded • Tachycardia (heart rate>120 beats/min.)

39. Peripartum Cardiomyopathy of:

40. Epidemiology of: • 4% of all cardiomyopathies • Incidence: • Geographic variations exist • 1 in 500–4000 in the USA • 1 in 1000 in South Africa • 1 in 300 in Haiti

41. Epidemiology of: • CDC Pregnancy Related Mortality Surveillance 1991-1999 • Leading Causes of Maternal Mortality: • Embolism – 20% • Hemorrhage – 17% • Hypertension – 16% • Peripartum Cardiomyopathy- 9%*

42. Epidemiology of: • 78% present within the first 4 months postpartum • Only 9% may present in the last month of pregnancy

43. Etiology of: • Etiology of this disorder is unclear. • Proposed mechanisms: • nutritional deficiencies • genetic disorders • viral or autoimmune etiologies • hormonal problems • volume overload • alcohol • physiologic stress of pregnancy • unmasking of latent idiopathic dilated cardiomyopathy

44. Clinical Presentations • Third heart sound (S3): 92% • Fourth heart sound (S4) • Tricuspid or mitral insufficiency murmurs: 43% • Displaced apical impulse: 72% • Edema • Rales • Ascites • Hepatomegaly • Jugular venous distension

45. Alogorithm

46. Diagnostics • Electrocardiogram or • β-type Natriuretic Peptide and • Cardiac Imaging: • Echocardiography • Cardiac MRI

47. Patient’s ECG

48. PPCM ECG LVH: 66% NSSTTWC: 96%

49. BNP • As a result of elevated LV end-diastolic pressure due to systolic dysfunction, patients with PPCM commonly have an increased plasma concentration of B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP). • 38 patients with PPCM were compared with 21 healthy mothers post-partum: • PPCM mothers: all had abnormal NT-proBNP plasma levels (mean 1727.2 fmol/mL) • Healthy mothers: mean 339.5 fmol/mL • P < 0.0001

50. Patient’s Echocardiography