Delayed peripartum cardiomyopathy after emergency cesarean section

Corresponding author: Woo-Jong Choi, M.D., Ph.D., Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Pungnap-dong, Songpa-gu, Seoul 138-736, Korea. Tel: 82-2-3010-3868, Fax: 82-2-3010-6790, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC Peripartum cardiomyopathy (PPCM) is a primary myocardial disease without any demonstrable cause and with onset in the last month of pregnancy or within six months of delivery [1]. Mortality is as high as 20 to 50% [2]. PPCM may suddenly occur when medical monitoring has been neglected and should be managed with great care by anesthesiologists and obstetricians. A 40-year-old (weight 81.5 kg, height 157 cm) multigravida (1-0-1-1) was admitted at 34 weeks 1 day of gestation with a chief complaint of preterm labor. Her medical history included obesity and gestational diabetes mellitus in a previous pregnancy. At 32 weeks gestation, she developed gestational hypertension without other significant preeclampsia signs and symptoms. At the time of admission the patient had a blood pressure (BP) of 180/100 mmHg, heart rate (HR) of 106 beats/ min and respiratory rate (RR) of 20 breaths/min. She was diagnosed with pregnancy-induced hypertension, preterm labor occurred so emergency cesarean section was decided. Physical examination yielded no specific findings. In blood tests hemoglobin was 14.5 g/dl, hematocrit 40.9%, and coagulation and electrolyte were within normal range, as were chest x-ray and electrocardiogram (ECG). Hence combined spinal-epidural anesthesia was planned. The patient arrived in the operating room with premedication and antacids. ECG, non-invasive blood pressure and pulse oxymetry were monitored. Vital signs were BP 178/105 mmHg, HR 112 beats/min, RR 20 breaths/min and oxygen saturation 96%. Oxygen was administered via nasal prong at 2 L/min. Combined spinal epidural technique (Portex, Smith Medical International Ltd, Kent, UK) with 7 mg of 0.5% heavy bupivacaine and 15 μg of fentanyl was done in left lateral decubitus position and midline approach at L3-4 interspace. Level of block was checked after 5 and 10 minutes and was found to be up to thoracic 6 and 4 segment respectively. Surgery proceeded without event and a healthy baby was delivered. Intravenous Carbetocin (Duratocin, Ferring International Center, Switzerland) 100 μg and midazolam 2 mg were given after delivery. Total estimated blood loss was 700 ml. The patient received 2,000 ml of lactated Ringer’s solution, and urine output was 200 ml. The operation lasted 65 minutes without adverse hemodynamic events. Patient was transferred to the postanesthetic care unit and then, over an hour later, to general ward, with stable vital signs. On POD 2, the patient’s general condition was good but as her BP was 160-180/90-110 mmHg, anti-hypertensive medication was given. She was supposed to be discharged on POD 4, but suddenly had chest pain and dyspnea, and oxygen saturation by pulse oxymetry became unstable as 81%. Accordingly, oxygen was administered via a reservoir mask, but oxygen saturation continued to be unstable. Immediately, endotracheal intubation and cardiopulmonary cerebral resuscitation were performed and the patient was transferred to the intensive care unit. On chest x-ray the patient had both pulmonary edema and cardiomegaly. Arterial blood gas analysis (FiO2 0.6) gave pH of 7.24, CO2 of 50 mmHg, O2 of 66 mmHg, bicarbonate of 22 mEq/ L, base excess of 6.0 mEq/L and oxygen saturation of 95%. Laboratory results at that time were B-type natriuretic peptide (BNP) 2,114 pg/ml and D-dimer 3.18 pg/ml; other laboratory tests were within the normal range. A computed tomography