New-onset Peripartum Cardiomyopathy with Focal Pulmonary Edema Masked as Pneumonia Leads to Acute Decompensation in Labor Necessitating Urgent Cesarean Delivery

 

Payton Marshall, MD, PhD; Ben Deverett, MD, PhD; David L. Stahl, MD, FASA; Igor Feinstein, MD, PhD; Julio-Santiago Perez, MD; Emily Stockert, MD, MBA

 

Peripartum Cardiomyopathy: New-onset systolic heart failure in pregnancy without prior cardiac disease or identifiable cause

 

Incidence and Risk Factors

Incidence: 1/4000 (U.S.); up to 1/100 (developing regions)¹

Risk factors: African descent, age>25, preeclampsia/eclampsia, multiple gestation, grand multiparity, cocaine use, prolonged tocolysis¹

 

Clinical Presentation and Differential

Clinical Presentation: dyspnea, fatigue, cough, PND, edema, hemoptysis^2,3

Differential: Takotsubo cardiomyopathy, arrhythmia-induced cardiomyopathy, preeclampsia/eclampsia-related cardiac dysfunction, amniotic fluid embolism^2,3

 

Diagnostic Criteria (NHLBI/ESC)

-  HF at the end of pregnancy or early postpartum

-  No prior heart disease or alternative cause^1,4

-  ECHO evidence: LVEF<45%, FS<30% (NHLBI), LV dilation (NHLBI) ^1,4

Expanded: early PPCM (late pregnancy), late (6-12 months postpartum)¹

 

Management

Delivery

CHF Treatments: sodium restriction, GDMT

Extremis: inotropes, mechanical support (ECMO, VAD, ICD), heart transplant.^2,3

 

Clinical Presentation: 39-year-old G4P2 with HTN, GDM, asthma presents at 37w gestation with mild dyspnea on exertion

Initial Workup and Intrapartum Course

-  CXR: Bilateral interstitial opacities reflecting pulmonary edema

-  CTPE (Right): Focal ground glass opacities concerning for atypical PNA

-  Started on amoxicillin/azithromycin

-  ECHO: Global hypokinesis, LVEF 31%, Moderate MR

Decision to proceed with induction of labor given mild symptoms

-  Contraction pain managed with neuraxial analgesia

-  Acute decompensation and hemodynamic instability  norepinephrine gtt

-  Worsening pulmonary edema  Initiation of diuretics

Maternal intolerance of labor induction remote from delivery, decision to proceed with cesarean section under carefully titrated neuraxial anesthesia

-  Epi + Dobutamine for vasoactive support

-  Delivery of vigorous neonate with APGAR 8 (1min) and 8 (5min)

-  Ventricular bigeminy throughout case into postpartum period

Postpartum

CVICU Admission, diuresis, euglycemic DKA

-  ECHO: LVEF 29%, Severe MR w/ flow reversal in right pulmonary vein

-  Discharged on GDMT (spironolactone, sacubitril/valsartan, empagliflozin, furosemide, carvedilol)

-  LifeVest, Ziopatch

 

Teaching Points

In This Case

-  CTPE with findings of pneumonia due to focal nature, despite being pulmonary edema on CXR

-  Acute MR resulted in flow reversal into the right pulmonary vein creating focal opacities

-  Labor analgesia with plain epidural (institutional standard dosing) unmasked hemodynamic instability

-  Delivery resulted in rapid discontinuation of support, however EF remained low requiring GDMT, LifeVest, Ziopatch

For Treatment of PPCM

-  While most patients diagnosed in first trimester, presentation can be as late as delivery

-  Even low dose epidural can unmask a well compensated hemodynamic instability

-  Delivery often leads to rapid improvement of symptoms

-  While most patients fully recover, chronic cardiac pathology is possible

 

 

1 Heart Fail Rev. 2024;29(6):1261–1278 2 Curr Heart Fail Rep.2018;15(5);297-306 3 Trends Cardiovasc Med. 2019;23(3):164-173 4 Medicine (Baltimore). 2018;97(31);e11516