CASE REPORT

PERIPARTUM CARDIOMIOPATHY
PRESENTED BY:
DWI YUNIA NINGSIH

COACH :
dr. PRIHATI PUJOWASKITO,Cardiologyst
Identity
 Name : Mrs. SM
 Sex : Female
 Age : 28 years old
 Address :kmp. Rihapti Timur no. 26
 Job : Housewife
 Religion : Islam
 Hospitalization: 16st November 2016 at 11.40 a.m
Clinical history
Chief Complaint
 Shortness of breath
Clinical History
History of Present Illness
 Breathlessness first felt since 10
months ago that after 2 months
postpartum her 2nd child and
become heavy since 3 months
ago and felt increasingly become
heavy since 3 days ago.
 Shortness of breath gets worse if
the patient activity
 Patients only sit and lie down
with 3 pillows.
 She is also have difficulty
sleeping at night because of
shortness of breath
 swelling in both legs since 3 months
ago.
 Dizziness
 Nausea without vomiting,
heartburn,
 Decreased appetite,
 Sometimes cough with phlegm that
is difficult to remove
 No complaints of chest pain but the
patient complained of chest
tightness like crushed by heavy
objects.
 There is no fever.
Clinical History
History of Past Illness
 History of hypertension  History swelling in both
during pregnancy second legs since 11 months ago,
child is at 7 months when the age of 8 months
gestation and remained of second pregnancy, hen
until now. swollen feet back 3 months
 History of hypertension ago.
before pregnancy (-)  History of PPCM (+)
 History of diabetes (-)
 History of asthma (-)
Family history Daily Habit
 In the family, noting  Smoking (-)
complaint like this  Drinking alcohol (-)
 History of hypertension in
the family denied
 History of diabetic in the
family denied
Physical Examination
General State
 Awareness: Compos  Eyes: Ca (+/+)
Mentis  Thorax :
 BP : 180/130 mmHg Pulmo: ves(+/+), Rh (+/+)
Cor: SI/SII regular, murmur
 HR : 112 x/mnt systolic (+), grade III/6,
 RR : 32 x/mnt punctum maksimum at
 T : 36.60C miteral valve
Heart border: kardiomegali
 Ekstremitas : edema leg
(+/+)
Laboratory Examination
Hematologi (16/11/16)
 Hb : 9,7 gr/dl (11.0-16.0
g/dl)
 Ht: 30 % (36.0-48.0 %)
 Leukosit: 7500/mm3
(4.000-10.000)
 Trombosit: 358.000/mm3
(150.000-450.000/mm3)
 Eritrosit: 3.9 juta/mm3
(4.0-5.5 juta/mm3)
Kimia Klinik
 Blood sugar : 91 mg/dl
(<160 mg/dl)
 Kidney Function :
Ureum: 223 mg/dl (10-50
mg/dl)
Creatinin: 10 mg/dl (0.6-1.1
mg/dl)
LFG : (140 – 28 )x 40 x 0,85
: (72x 10) = 5,3
ml/mnt/1,732m2
Laboratory Examination
Profile Lipid
 Trigliserida: 51 mg/dl
(60-200 mg/dl)
 LDL Kolesterol : 98
mg/dl (<115 mg/dl)
 Electro Cardiografy (ECG)

interpretation:
Rhythm: Sinus
Heart Rate (HR): 120 times per minute, regular.
Axis: normoaksis
Morphological abnormalities wave: T inverted in leads I, aVL, and q pathological in V1, V2, V3, V4, poor R wave
progression in V1-V4, LVH (+)
Impression: Sinus Tachycardia with OMI anteroseptal and LVH
Rontgen Thoraks
 Kardiomegali
Ekokardiografy (17/11/2016)

- Decreased LV systolic function (EF: 23%)

- Global Hypocinetic, mild MR, LV systolic dysfunction, RV systolic Dysfunction
Summary: PPCM
Resume
 A 38-year-old woman was complained about shortness of breath.
 Breathlessness first felt since 10 months ago that after 2 months
postpartum her 2nd child and become heavy since 3 months ago
and felt increasingly become heavy since 3 days ago.
 Dyspnea d'effort (+), tachipnea (+), and paroxysmal nocturnal
dyspnea (+), swelling in both legs since 3 months ago,
dizziness,nausea without vomiting, heartburn,decreased appetite.
 History of hypertension during pregnancy(+), History swelling in
both legs since 11 months ago, when the age of 8 months of
second pregnancy, then swollen feet back 3 months ago.
 History of heart disease (-), History of hypertension before
pregnancy (-), History of diabetes (-) History of asthma (-)
 In the family, noting complaint like this. History of hypertension in
and diabetic in the family denied.
 Physical Examination: compos mentis, hypertension emergency
(180/130 mmHg), takikardi (112x/mnt), tachypnea (32 x/mnt),
CA(+/+), thorax: pulmo : ves(+/+), rh (+/+), whz(-/-), Cor :
SI/SII regular, murmur sistolik (+) grade III/6 punctum
maksimum at miteral valve, Cor borderline: kardiomegali,
ekstremitas : edema at legs (+/+).
 Laboratory Examination: anemia, decreased kidney function.
 ECG: Sinus Tachycardia with OMI anteroseptal and LVH
 Rontgen thoraks : kardiomegali
 Echocardyografi : Decreased LV systolic function (EF:
23%) Global Hypocinetic, mild MR, LV systolic
dysfunction, RV systolic Dysfunction. Summary: PPCM
Suggestions Examination
 Serum albumin
 Checking electrolyte
 Blood gas analysis
 Cardiac Marker
 Check hematology and ginjal funtcion (ur, cr)
 Examination of serum digoxin levels
 check serial ECG
Diagnosis
 Clinical diagnosis: Congestif Heart Failure stadium C with
Nyha class IV
 Anatomical diagnosis: Left Ventricular hypertrophy
 Diagnosis etiology: Hypertensi
 Additional Diagnosis: CKD stage V
Management
Non Medical: medical:
 Bed rest  IVFD RL 500 cc / 24
 Oxygen 4 lpm
hours
 Furosemide 3 x 40 mg iv
 A diet low in salt and low
in protein  Digoxin 1 x 0,125 mg
 Simarc 1x2 mg
 Restriction of fluid intake
 Valsartan 1 x 80 mg
 Atorvastatin 1 x 20 mg
 Consul internist for
hemodialysis
Prognosis
 Quo ad Vitam : Dubia ad Malam
 Quo ad Sanactionam : Dubia ad Malam
 Quo ad Functionam : Dubia ad Malam
PPCM
Definition
 Peripartum cardiomyopathy (PPCM) is an uncommon
disorder associated with pregnancy in which the heart dilates
and weakens, leading to symptoms of heart failure.
 PPCM is diagnosed when the following3 criteria are met:
1. Heart failure develops in the last month of pregnancy or
within 5 months of delivery.
2. Heart pumping function is reduced,with an ejection fraction
(EF) less than 45% (typically measured by an
echocardiogramas described below).
3. No other cause for heart failure with reduced EF can be
found.
Epidemiology
 PPCM is rare in the United States,Canada, and Europe, with
an estimated case rate of 1 per 2500 to 4000 live births. This
translates to 1000 to 1300 woman developing PPCM each
year in the United States.
 Most patients (80%) present within 3 months of delivery,
with the minority presenting in the last month of pregnancy
(10%) or 4 to 5 months postpartum (10%).
 Some specialists believe that the definition of timing is too
strict and that patients who develop symptoms of heart
failure during the second or early third trimester should also
be diagnosed with PPCM
Risk factors
 Older maternal age
 Multiparity (1 or more priorpregnancies)
 Multifetal pregnancy (eg, twins)
 African descent
 High blood pressure
 Prior toxin exposure (eg, cocaine)
 Use of certain medications to prevent premature labor
 It is important to note that although PPCM is more likely to occur in a
woman over the age of 30 who is pregnant with twins and has had prior
pregnancies, PPCM can also occur in a young woman who is pregnant
with her first child.
Etiology
Still unknown.
 nutritional deficiencies
 small vessel coronary artery abnormality
 hormonal effects
 toxemia
 maternal immunologic response to fetal
antigen or
 myocarditis
Symptom
Evaluation
 This includes tests to assess kidney, liver, and thyroid
function;tests to assess electrolytes, including sodium and
potassium; and a complete blood count to look for anemia or
evidenceof infection.
 Markers of cardiac injury and stress such as troponin and B-
type natriuretic peptidecan be used to assess level of risk.
 Laboratory tests may also be done to rule out other causes of
cardiomyopathy such lupus and human immunodeficiency
virus.
 Chest x-ray to look for enlargement of the heart and fluid in
the lungs.
 Chest computed tomography (CT) scan to rule out blood
clots in the lungs,
 Electrocardiogram (heart tracing)to assess heart rate and
rhythm,to look for abnormal electric conduction,and to rule
out a heart attack.
 Echocardiogram (heart ultrasound)to assess the size and
function of the heart and to exclude other causes of heart
failure such as valve dysfunction or a congenital heart defect.
 Cardiac catheterization with coronary angiography
 Other imaging studies to look for inflammation or scarring
of the heart muscle, including cardiac magnetic resonance
imaging (MRI) and nuclear heart scans.
Management
 Vasodilators: During pregnancy, the vasodilator of choice is
hydralazine, which can be given alone or with nitrates. After
pregnancy, angiotensin-converting enzyme (ACE) inhibitors
or angiotensin receptor blockers.
 Diuretics
 β-Blockers
 Digitalis
 Spironolactone
 Anticoagulants
 Antiarrhythmics
Prognosis
 50% recover normal heart function, 25% have persistently reduced
heart function but remain stable on medications, and 25% progress to
severe heart failure.
 More recent research suggests that outcomes of PPCM have improved,
with survival rates as high
 as 90% to 95% with contemporary medical and device therapy (Figure).
 Although early improvement in EF (ie,within the first 3–6 months)
predicts a good outcome, some women will have slow, gradual
improvement in EF over years. The decision of when to stop medications
after the heart fully recovers, usually defined as an EF greater than 50%,
remains controversial.
 Most physicians, however, agree that ACE inhibitors and β-blockers
should be continued for at least 1 year after normalization of EF.