A postpartum 34 year old female with a past medical history of hypertension presents for shortness of breath. Symptoms have been progressive over one month. She called EMS today when she was too short of breath to walk up one flight of stairs to care for her 13 week old infant. She denies fever, cough, chest pain, or recent illness and is not taking any oral contraceptives. Vital signs include Temp 99.0F, HR 96, BP 170/90, RR 22, SpO2 95% on room air. On exam, she has conversational dyspnea with no increased work of breathing. There are rales at the bilateral lung bases and 2+ pitting edema of the bilateral lower extremities. A bedside echocardiogram is notable for a dilated left ventricle with reduced ejection fraction. Which of the following is the most likely etiology of her symptoms?
A: Cardiac infiltrative disease
B: Coronary artery atherosclerosis
C: Venous thromboembolism
D: None of the above
Answer: None of the above
This patient is likely presenting with peripartum cardiomyopathy, a rare but potentially fatal complication of pregnancy. The cause is unknown and most commonly occurs in the last month of gestation or within 5 months of delivery. The presenting symptoms and overall management of the condition are similar to other causes of congestive heart failure. Most patients will recover normal ejection fraction within the first 6 months of delivery. Ventricular dysrhythmias caused by persistent dilated cardiomyopathy may warrant an implantable defibrillator-pacemaker.
Cardiac infiltrative diseases such as amyloidosis or sarcoidosis most commonly cause diastolic dysfunction, not systolic dysfunction. Coronary artery disease is the most common cause of congestive heart failure but is unlikely in a 34 year old with minimal risk factors. A pulmonary embolism would cause right heart failure, not left ventricular systolic dysfunction.
| Peripartum Cardiomyopathy |
| Most commonly occurs in last month of pregnancy or within 5 months of delivery |
| Dilated cardiomyopathy without previous heart disease |
| Treat similarly to other causes of congestive heart failure |
| Majority of patients recover normal ejection fraction |
References:
Young JS. Maternal Emergencies After 20 Weeks of Pregnancy and in the Peripartum Period. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.
Arany Z, Elkayam U. Peripartum Cardiomyopathy. Circulation. 2016 Apr 5;133(14):1397-409. doi: 10.1161/CIRCULATIONAHA.115.020491. PMID: 27045128.
“Peripartum Cardiomyopathy – Summary 1. Definition …” GrepMed, 16 Sept. 2020, www.grepmed.com/images/10231/peripartum-treatment-diagnosis-management-cardiomyopathy. Accessed 4 Apr. 2024.
