RCOG World Congress 2025

A Rare Case of Antenatal Cardiomyopathy.

Rowland-Jones B1; Hashemi S1; Cox N1. 1 Queen Alexandra Hospital, Portsmouth.

BACKGROUND

36-year-old female

South Asian descent

G3P2 – 2 vaginal deliveries

MCDA twins

PMHx –GDM on metformin, Rh+, NKDA, diagnosed with Covid-19 3 weeks ago

Presented to hospital at 33+2 with PPROM. Transferred from a smaller unit to QAH.

The case:

The Day Post Admission (D2)

Developed heart palpitations and SOB.

HR 125, RR 20-23, SpO2 93% on air

ECG reported by cardiology reg as normal

Approx. 10-minute episode of reduced consciousness with residual left arm numbness.

Blood gas at the time: pH 7.51, pO2 24.0, pCO2 1.6, BE -13.3, HCO3 16.5, Lac 2.6, Glu 7.3

Differential Diagnosis?

-PE

-Starvation ketoacidosis

-State of anxiety.

Management:
1. IV fluids

2. Treatment dose enoxaparin

3. CTPA requested

Despite IV fluids, lactate continues to rise to 5.3. Ketones are 2.5

CTPA reported - negative for PE

Ongoing tachycardia and tachypnoea

PE excluded

Is this starvation ketoacidosis on a background of taking metformin?

Management::

Commenced on the DKA pathway

Improvement in blood gas noted

During this time…

Emergency buzzer for 4-minute fetal bradycardia which resolved.

Referrals sent for advice…

(Day 2) 10:00pm-12:00am

Med reg review:

Stop DKA protocol – completed 3L of IV fluids

Advised a cardio review

Cardiology review:

Bedside ECHO – overall normal, tachycardic during study

(Day3) Approximately 09:00am

Fetal bradycardia = Category 1 emergency csection under GA (due to treatment dose enoxaparin)

GA LSCS

•Stable on induction.

•No complications with intubation

•EBL 1.8L with 1.5L of fluid replacement (unlikely fluid overload as a cause)

•Extubated uneventfully

•HOWEVER

In theatre recovery…

Drowsy and desaturated whilst lying flat – required a non rebreathe face mask. No improvement with recruitment manoeuvres and wet sounding cough

Consultant anaesthetist attended – repositioned and SpO2 increased to 100%.

A few minutes later…

SpO2 dropped again to 89%, RR 30, HR 130, BP 150/90

No change with recruitment exercises

Management:

1.Portable CXR à Diffuse bilateral pulmonary oedema and visually an enlarged cardiac shadow

2.ITU review: à 40mg IV furosemide given and CPAP commenced, switched to concentrated Oxytocin given

3.ECG à tachycardia and anterior T wave inversion (no change from admission)

4.Cardiology review à Troponin = 427. ECHO: severely impaired systolic function in the presence of tachycardia at 141bpm, visual EF <20%, septal akinesia

Impression – flash pulmonary oedema likely secondary to post-partum cardiomyopathy

Transferred to ITU:

Management:

- Commenced on CPAP (10) – Aim PaO2 >8

- Commenced on IV furosemide – Aim to be 2L negative in 24 hours

- Commenced on GTN infusion – Aim for SBP <140

- Commenced on IV antibiotics as pyrexia developed on arrival to ITU – Septic screen performed

Later that evening:

Overall O2 requirements improving - Switched to 60L high flow nasal O2 at 50% FiO2 with intermittent episodes of CPAP –

Lactate improved to 1.0

GTN stopped as maintaining BP

Next day:
Ejection fraction improved to 35-40%

Troponin trending down

CPAP stopped, O2 requirement trending down

Transferred to cardiology

Cardiology outcome and follow-up

•4/7 post event CT cardiac angiogram showed no plaque or dissection

•Cardiac MRI 7/7 post event findings were in keeping with acute LAD infarction, on further review of angiogram post MRI, focal haziness at proximal LAD with luminal narrowing, highly concerning for acute dissection

LEARNING POINTS & CONCLUSION

•Spontaneous coronary artery dissection (SCAD) is a rare cause of cardiogenic shock, but is often related to those people with little to no cardiac history and is a more common cause of MI in pregnancy(a)

•Often associated with left anterior descending, left main and multivessel disease with PCI not having a high success rate in treatment and patients often having a high risk for further cardiac events in the future(a)

•There should be a broad range of differentials when flash pulmonary oedema occurs in pregnancy to avoid missing a diagnosis(b)

•There is a link between SCAD and connective tissue disorders (Ehlers-Danlos Syndrome)(b)

References

a)Pregnancy and the Risk of Spontaneous Coronary Artery Dissection, An Analysis of 120 Contemporary Cases , Ofer Havakuk, MD; Sorel Goland, MD; Anil Mehra, MD; Uri Elkayam, MD (Circ Cardiovasc Interv. 2017;10:e004941. DOI: 10.1161/CIRCINTERVENTIONS.117.004941.)

b)Pregnancy-related spontaneous coronary artery dissection: a rare cause of acute coronary syndrome in the third trimester, Kenny Vongbunyong1*, Frederick Chua1 and Roxana Ghashghaei2, BMC Cardiovascular Disorders (2023) 23:292https://doi.org/10.1186/s12872-023-03323-7

RCOG World Congress 2025

A rare case of antenatal cardiomyopathy

Poster Presenter

Authors

Affiliations

Part of Topic