Challenges In The Anesthetic Management Of Peripartum Cardiomyopathy Undergoing Emergency Ceserean Section

Peripartum cardiomyopathy (PPCM) is an unusual form of dilated cardiomyopathy which manifests as acute heart failure in the last trimester of pregnancy or early postpartum period. Choice of anaesthesia is based on the urgency of lower segment caesarean section and severity of PPCM. Here we report a 31year old female G3P2L2 36weeks + 2days diagnosed as Peripartum Cardiomyopathy came with complaints of leaking per vagina was taken up for emergency caesarean section under general anaesthesia. In this case report, we discuss the anaesthetic management of a case of PPCM posted for emergency caesarean section with intra-operative event of desaturation. Anaesthetic management was directed towards optimization of desaturation, myocardial contractility, preload and after load. No adverse events or complications were observed.

A STUDY OF PERIPARTUM CARDIOMYOPATHY AMONG CASES OF PREECLAMPSIA AND ECLAMPSIA.

Peripartum cardiomyopathy is a rare complication in pregnancy but is more commonly found in the patients of preeclampsia and eclampsia. The purpose of study is to evaluate incidence of peripartum cardiomyopathy among cases of preeclampsia and eclampsia. This is a prospective observational study. A total of 190 cases of preeclampsia and eclampsia were studied for features of PPCM and subjected to echocardiography. Out of 190 subjects, 3.7% had ?ndings suggestive of PPCM. Incidence of PPCM was 0.009 per year among cases of pre-eclampsia and eclampsia and the incidence of PPCM among 6028 deliveries was 0.001 per year.

Miocardiopatía periparto: revisión de la literatura / Peripartum Cardiomyopathy

Resumen: La Miocardiopatía Periparto es una patología que se presenta como una insuficiencia cardíaca aguda que aparece en el último mes del embarazo o los primeros 5 meses post parto, en ausencia de otra causa identificable. A pesar de ser más frecuente en países Afrodescendientes, el efecto migratorio ha provocado un aumento en su incidencia en los países de América latina, influyendo en la morbimortalidad materna. Si bien su etiología aún no está claramente definida, se han propuesto algunos mecanismos como el aumento del estrés oxidativo, el desequilibrio de la angiogénesis y las reacciones inflamatorias que, en un organismo genéticamente predispuesto, podrían ser los desencadenantes de esta enfermedad. Su manejo aún se considera de soporte, pero se sigue investigando en alternativas terapéuticas que puedan mejorar los resultados a largo plazo. Así, el motivo de esta revisión es evaluar la evidencia disponible hasta el momento, para el enfrentamiento del equipo tratante de estas pacientes.

Abstract: Peripartum Cardiomyopathy is a diseae presenting as acute heart failure that appears in the last month of pregnancy or within 5 months postpartum, in the absence of other identifiable cause. Despite being more frequent in Afro-descendant populations, the migratory effect has caused an increase in its incidence in Latin American countries, influencing maternal morbidity and mortality. Although its etiology is not yet defined, some mechanisms have been proposed such as increased oxidative stress, angiogénesis imbalance and inflammatory reactions that in a genetically predisposed organism, could be the triggers of this disease. Supportive therapy is still the initial management. Therapeutical alternatives that are still being investigated. The main purpose of this review is to evaluate the evidence available to improve the prognosis of the disease.

Pre-pregnancy obesity and the risk of peripartum cardiomyopathy: A systematic review and meta-analysis

The outcome of this review is to assess the association between pre-pregnancy obesity and PPCM incidence. There were a total of 5.373.581 participants were included in this study. Pre-pregnancy obesity was significantly associated with PPCM incidence compared to normal-weight subjects (OR ¼ 1.79 (1.16,2.76); p ¼ 0.008; I 2 ¼ 59%, Pheterogeneity ¼ 0.04). The sub-group analysis showed that pre-pregnancy women with obesity class I (OR ¼ 1.58 (1.20,2.07); p ¼ 0.001; I 2 ¼ 0%, Pheterogeneity ¼ 0.64) and class II and III (OR ¼ 2.65 (2.04,3.45); p < 0.001; I 2 ¼ 6%, Pheterogeneity ¼ 0.36) was significantly associated with PPCM incidence compared to normal-weight subjects.

Insuficiencia cardiaca congestiva en el embarazo, secundaria a miocardiopatía periparto. Reporte de caso / Congestive heart failure in pregnancy secondary to peripartum cardiomyopathy. Case report

Resumen INTRODUCCIÓN: En Estados Unidos, las cardiopatías periparto se registran en 1 de cada 4000 pacientes. Se consideran idiopáticas y se asocian con enfermedades genéticas, problemas inmunológicos y malformaciones cardiacas, sin que se tenga certeza del origen real de este tipo de enfermedades. La miocardiopatía periparto se asocia con el embarazo y el puerperio; los criterios diagnósticos incluyen: a) insuficiencia cardiaca en las últimas cuatro semanas del embarazo o en los cinco meses siguientes al parto, b) ausencia de causas identificables de insuficiencia cardiaca, c) ausencia de enfermedad cardiaca demostrable antes de las últimas cuatro semanas del embarazo y alteración de la función del ventrículo izquierdo (fracción de eyección del ventrículo izquierdo, menor del 45%). La presentación del caso ayudará a que se tenga conocimiento de este problema. CASO CLINICO: Paciente de 26 años, en curso de las 35.4 semanas de embarazo, con inicio abrupto de signos de cardiopatía congestiva: tos, edema, taquicardia e hipertensión arterial. El embarazo finalizó por cesárea, con traslado inmediato a la unidad de cuidados intensivos. La ecocardiografía reportó una valvulopatía no conocida, insuficiencia ventricular izquierda y disminución de la fracción de eyección del ventrículo izquierdo; con lo anterior se integró el diagnóstico de miocardiopatía periparto. CONCLUSIONES: Las cardiopatías periperiparto son alteraciones excepcionales, con cuadros clínicos debidamente definidos y diagnóstico complejo. Las valvulopatías son el último diagnóstico diferencial de cardiopatía congestiva peripuerperal y se han descrito pocos casos asociados con miocardiopatía periparto.

Abstract BACKGROUND: Peripartum heart disease occurs in 1 out of 4000 cases in the United States; currently, its exact origin is unknown, which is why they are called idiopathic. Genetic diseases, immunological problems and heart malformations have been associated, without being certain about the real origin of these pathologies. Peripartum cardiomyopathy is a rare pathology associated with pregnancy and the puerperium, the diagnosis criteria includes: a) Development of heart failure in the last month of pregnancy or in the 5 months after delivery, b) absence of identifiable causes of heart failure, c) absence of demonstrable heart disease prior to the last month of pregnancy and impaired left ventricular function (FEVI less than 45%). The presentation of the case will help to raise awareness about this problem. CLINICAL CASE: A 26-year-old female patient coursing second gestation in the 35.4 pregnancy week, who debuts abruptly with signs of congestive heart disease such as cough, edema, tachycardia and arterial hypertension. The pregnancy was solved by cesarean section with a subsequent stay in Intensive Care Unit, an unknown valvular disease was identified by echocardiography, as well as left ventricular failure and decreased FEVI. Finally, a definitive diagnosis of peripartum cardiomyopathy was integrated. CONCLUSIONS: Peripartum heart disease is a rare occurrence, with well-defined clinical pictures, but difficult to approach and diagnose. Where valvular heart disease is the last differential diagnosis for peripuerperal congestive heart disease, and few cases associated with peripartum cardiomyopathy have been described.

Miocardiopatía periparto en 2021: ¿con qué contamos para su tratamiento? / Peripartum cardiomyopathy in 2021: what is available for its management?

Resumen Introducción La miocardiopatía periparto (MCPP) es una condición que afecta a mujeres al final del embarazo o durante los primeros meses del periodo puerperal, caracterizada por insuficiencia cardiaca secundaria a disfunción sistólica del ventrículo izquierdo de origen idiopático; por lo tanto, esta se considera un diagnóstico de exclusión. El manejo de la MCPP resulta ser un reto que requiere un abordaje multidisciplinario que debe incluir, como mínimo, al cardiólogo y al obstetra, ya que existen especiales consideraciones debido a las precauciones que deben tomarse en cuenta para conservar la salud fetal y materna. Objetivo Realizar una revisión sobre la evidencia científica disponible hasta la fecha en relación con el tratamiento de la MCPP. Método: Se realizó una revisión sistemática de la literatura en la base de datos PubMed bajo los siguientes términos: peripartum cardiomyopathy, pregnancy and heart failure y pregnancy and cardiomyopathy. Se seleccionaron artículos sin restricción de idioma ni fecha de publicación. Conclusiones Ha habido un incremento en el conocimiento de ciertos aspectos sobre la MCPP en los últimos años; sin embargo, queda mucho por conocer con respecto a sus mecanismos patogénicos. Si bien la bromocriptina parece ofrecer buenos resultados, es necesaria mayor investigación para averiguar su verdadero rol en esta condición. Deben realizarse más estudios para evaluar los posibles beneficios y la seguridad de las nuevas terapias propuestas.

Abstract Introduction Peripartum cardiomyopathy (PPCM) is a condition that affects women towards the end of pregnancy or during the first months after delivery characterized by heart failure secondary to left ventricle systolic dysfunction of idiopathic origin, thus, it is considered as an exclusion diagnosis. PPCM management is a challenge that requires a multidisciplinary approach that must include at least the cardiologist and the obstetrician because of the precautions that must be considered to preserve fetal and maternal health. Objective To perform a review on the evidence available to date regarding the treatment of PPCM. Method A systematic review was performed on the PubMed database using the following terms: peripartum cardiomyopathy, pregnancy and heart failure y pregnancy and cardiomyopathy. Articles were selected with no language or publication date restrictions. Conclusions An increase in awareness of PPCM has occurred during the last few years, however, there is still much to discover about its pathogenic mechanisms. Bromocriptine therapy seems to offer goods results in these patients, further research is needed in order to know its true role in this condition. Other proposed therapies are yet to be studied to know their possible benefits and safety profile.

A propósito de la cardiopatía periparto: una etiología olvidada / Regarding peripartum heart disease: a forgotten etiology

Resumen Objetivo: Identificar la epidemiología clínica y los procesos diagnósticos y terapéuticos de las mujeres con miocardiopatía periparto en un centro de referencia cardiovascular. Método: Se realizó un estudio observacional descriptivo retrospectivo con pacientes de sexo femenino de entre 15 y 50 años con diagnóstico de cardiopatía periparto durante los últimos 10 años en una institución especializada de la ciudad de Medellín. Resultados: Hubo 17 mujeres con diagnóstico de cardiopatía periparto, con una edad media de 31 años (± 6.7). El número promedio de embarazos fue de 1.0, con un 52.9%. Las condiciones más frecuentes durante la gestación fueron obesidad y preeclampsia, con un 23.5% para ambas; se halló diabetes gestacional en una paciente (5.9%) y dos presentaron hemorragia del primer trimestre (11.8%). El 41.2% de las mujeres tuvieron parto vértice espontáneo. Ninguna mujer tuvo antecedentes cardiovasculares. Los síntomas presentados al momento del diagnóstico fueron deterioro de la clase funcional (100%), edema en miembros inferiores (52.9%), ortopnea (76.4%) y disnea paroxística nocturna (88.2%). La terapia farmacológica iniciada incluyó diuréticos (58.8%), inhibidores de la enzima convertidora de angiotensina (IECA) (64.7%), betabloqueadores (82.4%), bromocriptina (5.8%), ivabradina (23.5%) y antagonistas de la aldosterona (64.7%). Conclusiones: Este registro señala la similitud en nuestro medio de esta enfermedad, respecto a la epidemiología, la presentación y el manejo, con el resto del mundo. Muestra que el tratamiento farmacológico para falla cardiaca con la combinación de betabloqueadores, IECA y diuréticos sigue siendo el pilar fundamental en el tratamiento; además, destaca que la miocardiopatía periparto aún es una afección grave, con alta morbilidad y que permanece en insuficiencia cardiaca después del diagnóstico y con un riesgo importante de mortalidad.

Abstract Objective: To identify the epidemiology and the diagnostic and therapeutic processes of women with peripartum cardiomyopathy on a cardiovascular reference center. Method: A retrospective descriptive observational study was conducted with female patients between 15 and 50 years of age with a diagnosis of peripartum cardiomyopathy during the last 10 years. Results: 17 women with a diagnosis of peripartum cardiomyopathy where included, with a mean age of 31 (± 6,7) years at the time of diagnosis. The average number of previous pregnancies was 1.0 in 52.9% of the population. Obesity and preeclampsia were present in 23.5% and 18.8%, respectively. Diabetes was found in one patient (5.9%) and two had hemorrhage of the first trimester (11.8%). 41.2% of the women had a spontaneous vertex delivery. The symptoms presented at the time of diagnosis were deterioration of their functional class in 100.0%, edema in the lower limbs in 52.9%, orthopnea in 76.4% and paroxysmal nocturnal dyspnea in 88.2%. Conclusions: Our data show that peripartum cardiomyopathy occurs with a mode of presentation similar to the rest of the world, pharmacological treatment for heart failure with the combination of beta blockers, ACE inhibitors/ARBs, and diuretics continue to be the fundamental pillar in the treatment of peripartum cardiomyopathy; It is also important to note that peripartum cardiomyopathy remains a serious condition with a high rate of critically ill patients who remain in heart failure after diagnosis with a significant risk of mortality.

Application of extracorporeal membrane oxygenation in critically ill pregnant women / 中华危重病急救医学

Objective:To investigate the safety and effectiveness of extracorporeal membrane oxygenation (ECMO) in emergency treatment of critically ill pregnant women.Methods:Clinical data of 8 pregnant women with severe cardiopulmonary dysfunction during the perinatal period treated by ECMO in the department of intensive care unit (ICU) of Nanjing Drum Tower Hospital, the Affiliated Hospital to Nanjing University Medical School from September 2017 to November 2020 were retrospectively analyzed. Results:For the 8 pregnant women, the mean age was (32.5±6.3) years old. Body weight was (73.5±8.1) kg. Gestational age was (31.0±4.4) weeks. Acute physiology and chronic health evaluationⅡ (APACHEⅡ) score was 13.0±6.6, and sequential organ failure assessment (SOFA) score was 8.3±3.8. Among them, 5 pregnant women suffered from severe pneumonia and were treated with veno-venous ECMO (VV-ECMO). Another 3 pregnant women with heart failure underwent veno-arterial ECMO (VA-ECMO). The initial ECMO flow rate was set to 2.0-3.0 L/min. Then the highest flow rate was (3.1±0.6) L/min, and the average ECMO running time was (174±36) hours. The length of ICU stay was (16.0±5.4) days. Six pregnant women (5 with severe pneumonia and 1 with peripartum cardiomyopathy) successfully evacuated from ECMO and survived. Two pregnant women with pulmonary hypertension showed poor prognosis. In total, seven babies survived. Two of them were delivered after ECMO evacution, and one underwent emergency cesarean section with ECMO support. In another case, the fetus could not be delivered due to under-gestational weeks. During this period, there were no serious bleeding complications. One pregnant woman developed heparin-induced thrombocytopenia and thrombosis (HITT), then she received another anticoagulant treatment. One pregnant woman got sequential anticoagulation therapy for 3 months on account of thrombosis in the puncture vessel.Conclusions:ECMO has played an active role in the rescue of critically ill pregnant women. For those with reversible severe cardiopulmonary dysfunction, it is necessary to evaluate the application of ECMO as early as possible to improve the survival rate of mothers and infants.

Clinical profile and outcome of Peripartum Cardiomyopathy among teenager patients at the University of the Philippines - Philippine General Hospital

@#<p style="text-align: justify;"><strong>Background.</strong> Peripartum cardiomyopathy (PPCM) is a rare form but life-threatening disease condition of the myocardium resulting in decreased ventricular contractility that occurs in a previously healthy woman during the peripartum period. Currently, in our country and probably worldwide there is an absence of epidemiologic data and description of the profile and outcome of PPCM patients less than 19 years old.</p><p style="text-align: justify;"><strong>Objective.</strong> To determine the clinical profile and outcome of peripartum cardiomyopathy among teenagers (14-18 years old) at the University of the Philippines-Philippine General Hospital from 2004-2013</p><p style="text-align: justify;"><strong>Methods.</strong> All patients aged 14-18 years old referred to Section of Pediatric Cardiology during a 10-year period from 2004-2013 who were diagnosed to have peripartum cardiomyopathy fulfilled the criteria set by National Heart, Lung and Blood Institute (NHLBI) were included in the study. We retrieved the medical records of the 25 patients diagnosed with peripartum cardiomyopathy from 2004-2013. The 2D echocardiogram was retrieved from the Pediatric Cardiology Section.</p><p style="text-align: justify;"><strong>Results.</strong> There were 25 teenagers with a mean age of 17 years old diagnosed with PPCM in UP-PGH in 2004-2013. Twenty-one patients (84%) had one sexual partner and two (8%) patients had multiple sexual partners. Their common co-morbidity was preeclampsia. The most common symptoms were dyspnea, easy fatigability, and orthopnea. Most patients presented with NYHA functional class III-IV.</p><p style="text-align: justify;">The majority had poor LV contractility (mean EF of 29% and a mean FS of 12.7 %). All had left ventricular enlargement with mean LVEDd of 5.3 cm and mean LVESd of 4.2 cm. LV function improved in 72% of patients after six months. Four (16%) patients died because of myocardial failure.</p><p style="text-align: justify;"><strong>Conclusion.</strong> Peripartum cardiomyopathy is a rare form of cardiomyopathy but it can occur among teenagers age 14-18 years of age. Compared with the previous study our patients are younger, and with a low prevalence of multiple pregnancy and promiscuity. Similar to other studies, preeclampsia and premature labor necessitating the use of tocolytics with Terbutaline are common comorbidities.</p>

Feto-maternal outcome in patients with peripartum cardiomyopathy: a 5-year study in a tertiary care hospital in Kolar district

Background: Peripartum cardiomyopathy (PPCM) is a disorder of unknown cause in which initial left ventricular systolic dysfunction and symptoms of heart failure occur between the last month of pregnancy and the first 5 months postpartum. PPCM remains a diagnosis of exclusion. There have been numerous proposed causes including hormonal abnormalities, inflammation, viral pathogens, autoimmune response, and genetic predisposition. Aim of study was to study the clinical profile, risk factors, and the management along with obstetric and perinatal outcome, in women with peripartum cardiomyopathy.Methods: This retrospective observational study was conducted on the antenatal women of age group of 18 years to 40 years, admitted in the labour ward of R. L. Jalapa hospital who presented with heart failure in last month of pregnancy till 5 months postpartum, without previously having a heart disease over the 5 year period, January 20 15 to December 2019.Results: Majority of the patients (15/18) presented with complaints of exertional dyspnoea. Mean LVEF at the time of diagnosis was 38.39%. There were 5 (27%) maternal mortality and all of them had global hypokinesia on echocardiography and presented in NYHA class III and IV. Two (11%) out of eighteen patients had intrauterine death, and all the patients who had IUFD belonged to class IV. Four babies (22.22%) had intrauterine growth restriction.Conclusions: The present study came to conclusion that in rural tertiary center, maternal outcome and prognosis was poor as patients presenting to us were majority of them in cardiogenic shock and lower LVEF in terminal stages. The associated risk factors were preeclampsia, anemia and multiple gestation which could also contribute to the poor prognosis which was noticed in the study. Early recognition of the disease is of paramount importance as the clinical manifestations can conceal and can lead to high morbidity and mortality especially within 3 months postpartum.

A clinical study on peripartum cardiomyopathy at tertiary care hospital

Background: Cardiac diseases complicate 1-4% of pregnancies in women without pre-existing cardiac abnormalities. Cardiac disease in the pregnant woman can present a challenge to the obstetrician, cardiologist and neonatologist. Peripartum cardiomyopathy (PPCM) is an idiopathic disorder defined as heart failure occurring in women during the last month of pregnancy and up to 5 months postpartum. Aim is to study the burden of the disease, maternal outcome in PPCM.Methods: The present study was conducted among the antenatal women admitted in the department of Obstetrics and Gynecology at KIMS, Hubli with a previously diagnosed cardiac disease or diagnosed after admission during index pregnancy from December 2016 to May 2018. The mothers were followed up till discharge. Maternal outcome was noted as discharged or died.Results: A total of 11 cases of PPCM noted in our study out of which one case was developed before delivery, and 10 cases developed postnatally. Out of ten cases which were developed postnatally, 5 patients died giving around 50% of mortality rate.Conclusions: PPCM affects previously normal healthy women in the last month of pregnancy and up to 5 months after delivery. Careful assessment of risk factors contributing PPCM could help in their prevention. And these patients should be stratified in developing PPCM in future pregnancies through proper tools available.

Miocardiopatía periparto: afección subvalorada / Peripartum cardiomyopathy: An undervalued disease

Resumen: El embarazo es un estado que impone un verdadero reto para el sistema cardiovascular materno. Existe remodelamiento cardiaco, que, junto con el incremento de la masa miocárdica y del tamaño del ventrículo izquierdo y la contractilidad miocárdica disminuida agravada por los cambios del embarazo, pueden condicionar insuficiencia cardiaca aguda durante el periodo periparto. Se considera miocardiopatía periparto cuando la función sistólica del ventrículo izquierdo y los síntomas de insuficiencia cardiaca ocurren en el último mes del embarazo y en los cinco meses posteriores al parto con incidencia de 1 por cada 1300 a 15,000 embarazos. Se comunica el caso de una paciente de 26 años, con antecedente de catarata congénita, que tuvo embarazo normoevolutivo, con parto eutócico, durante el puerperio tuvo disnea y datos de hipoperfusión, mediante evaluación ultrasonográfica pulmonar y cardiaca mostró datos de miocardiopatía dilatada periparto, fue trasladada a un hospital de tercer nivel, donde a pesar del tratamiento intensivo multidisciplinario, falleció. La miocardiopatía periparto es una enfermedad subvalorada con alta mortalidad materna y perinatal; sin embargo, la detección oportuna puede mejorar el tratamiento y el pronóstico. Con la comunicación de este caso, se pretende demostrar la importancia de la detección temprana de una afección poco diagnosticada, como es la miocardiopatía periparto.

Abstract: Pregnancy is a state that imposes a real challenge for the maternal cardiovascular system. There is a cardiac remodeling, which along with an increase in myocardial mass, in left ventricular size and decreased myocardial contractility aggravated by changes in pregnancy, can condition acute heart failure during the peripartum period. Peripartum cardiomyopathy is when the systolic function of the left ventricle and the symptoms of heart failure occur in the last month of pregnancy and in the five months after delivery with an incidence ranging from 1/1300 to 1/15,000 pregnancies. This paper reports the case of a 26-year-old female patient, who had a history of congenital cataract, with normal pregnancy and eutocic delivery; during the puerperium patient showed dyspnea, hypoperfusion data and pulmonary and cardiac ultrasonographic evaluation of peripartum dilated cardiomyopathy, being transferred at a third level, where despite intensive multidisciplinary treatment, the patient died. Peripartum cardiomyopathy is an undervalued disease that has a high maternal and perinatal mortality; however, a timely detection can improve treatment and prognosis. The purpose of this case report is to demonstrate the importance of early detection of a poorly diagnosed entity, such as peripartum cardiomyopathy.

Diagnosis and treatment of peripartum cardiomyopathy / 中国实用妇科与产科杂志

Typical symptoms of peripartum cardiomyopathy(PPCM)are heart failure and dyspnea.Echocardiography is the first choice.Bromocriptine and oral drugs for heart failure are the main treatments.For pregnant women with heart failure with hemodynamic instability,pregnancy should be terminated regardless of the size of the gestational age.The predictors of maternal mortality are NYHA class Ⅲ/Ⅳ and left ventricular ejection fraction(LVEF)<40%.

Biochemical and histological changes in the heart of post-partum rats exposed to Natron

Background The customary puerperal practice of Natron consumption has been identified as one of the predisposing factors in the etiology of peripartum cardiomyopathy (PPCM). This study was designed to investigate the effect of Natron in postpartum Wistar albino rats. Methods A total of 30 postpartum Wistar rats were exposed to different doses (50 mg/kg, 100 mg/kg, 200 mg/kg and 300 mg/kg) of Natron for 28 days. After the treatment, we carried out biochemical analyses and histological evaluations of kidney, liver and heart. Results The study revealed that the exposure of postpartum rats to 100 mg/kg of Natron and above significantly (p < 0.05) increase the cardiac markers; myoglobin, creatine kinase-MB, troponin I and T as compared with control. The result of liver function indicated no significant difference in alanine aminotransferase, aspartate aminotransferase, gamma-glutamyltransferase, albumin and total protein of the Natron treated groups as compared with control. However, at higher doses, the levels of total protein, globulin and alkaline phosphatase activity were significantly increased in comparison to the control. There was no significant difference in the kidney function markers of the treatment groups as compared with control. Histological examinations revealed no changes in the kidney of the treated groups. Mild portal triaditis was observed in the liver of the treated rats. The heart of the rats administered ≥100 mg/kg of Natron showed myocyte hypertrophy. Conclusion The study demonstrated that the administration of Natron for 28 days caused changes in the heart of postpartum rats and thus may contribute to the pathogenesis of PPCM.

Paciente haitiana embarazada de alto riesgo y utilidad del US en el diagnóstico diferencial en un PCR: presentación de un caso / High Risk Haitian Pregnant Patient and Utility of the Ultrasound in the Differential Diagnosis in a Cardiac Arrest: A Case Report

In the recent years, have been an increase in the number of pregnant patients of Haitian nationality in the Chilean public health service. This new population has a higher incidence of some pathologies as peripartum cardiomyopathy and sickle cell anemia which impact in the evolution of pregnancy and the anesthetic management of the peripartum. This article presents a case report of a 22 years-old hatian patient, with no known morbid history, who presents cardiac arrest during emergency cesarean section. In addition, it explains the method in which the diagnosis of peripartum cardiomyopathy was obtained, and how the reanimation and the differential diagnoses were guided by the use of ultrasonography. To conclude, it is crucial to develop screening methods to detect high-risk pregnant women and, at the same time, encourage the massification of tools, such as ultrasound [US], to manage critical situations that occurs more frequently in these patients.

Durante el último tiempo ha existido un incremento en el número de pacientes embarazadas de nacionalidad haitiana en el servicio de salud pública chileno. Esta nueva población trae consigo mayor incidencia de algunas patologías como cardiomiopatía del periparto y anemia falciforme, que condicionan la evolución del embarazo y el manejo anestésico del periparto. En este artículo se presenta el caso clínico de una paciente haitiana de 22 años, sin antecedentes mórbidos conocidos, que presenta un paro cardiorrespiratorio durante la cesárea de urgencia. Además, se explica la forma en que se obtuvo el diagnóstico de miocardiopatía del periparto, y cómo se guió la reanimación y los diagnósticos diferenciales mediante el uso de ultrasonografía. En conclusión se destaca que resulta imprescindible desarrollar métodos de screening para detectar embarazadas de alto riesgo y fomentar a su vez la masificación de herramientas, como el ultrasonido [US], para manejo de situaciones críticas que ocurren en mayor frecuencia en estas pacientes.

Insertion/deletion polymorphism of ACE gene in females with peripartum cardiomyopathy: A case-control study

Background The role of polymorphism of Angiotensin converting enzyme (ACE) gene and ACE activity in etiopathogenesis, prognosis, and many other clinical parameters in the various form of the cardiovascular disease has been established to some degree of certainty. The pathophysiology of Peripartum cardiomyopathy (PPCM) remains an area of active research. The main aim of our study was to see pattern of ACE- Insertion/Deletion (I/D) allele in PPCM and its implications on left ventricular performance indices. Methods This single-center case-control study included 45 cases and 70 controls. The diagnosis of PPCM was established clinically and echocardiographically. ACE genotyping was done by polymerase chain reaction (PCR) method in all subjects. Results The II, ID, and DD genotype was present in 16, 18 and 11 of subjects with PPCM and 48, 19 and 3 of controls respectively. The odds ratio for ACE-II genotype in cases vs. controls was 0.253 (95% CI = 0.114–0.558; p = 0.007), for that of II genotype was 1.93 (95% CI = 0.86–4.3; p = 0.107) and for DD genotype was 7.225 (95% CI; 1.88–27.6; p = 0.0039). Overall frequency of D allele in cases was significantly higher than controls (odds = 4.25; 95% CI = 2.01–6.7; p = 0.0001). Moreover, ejection fraction, left ventricular volume and linear dimensions were worse in patients with DD genotype. Conclusion ACE DD genotype and overall frequency of D allele is significantly higher in patients with PPCM. Also, the presence of DD genotype is associated with worse systolic performance indices measured echocardiographically.

Miocardiopatía periparto / Peripartum cardiomyopathy

Resumen Dentro de las indicaciones para practicarse una autopsia médico-legal en Costa Rica, se encuentran las muertes súbitas o causas judiciales para investigación por mala práctica médica, donde en ocasiones hay casos de mujeres en su embarazo tardío, así como en periodo post-parto. Este artículo busca conocer aspectos acerca de un diagnóstico específico que debe tomarse en cuenta durante el análisis forense en una autopsia de mujeres en periodo comprendido entre el último mes de embarazo y los 5 posteriores al parto: la miocardiopatía periparto. Esta entidad patológica se determina por su establecimiento en el lapso del tiempo anteriormente expuesto y trata de una forma de cardiomiopatía dilatada no tan habitual, pero con una morbimortalidad elevada y por tanto, en el ámbito de la patología forense es de carácter trascendental conocerlo. Este artículo busca conocer su fisiopatología, así como sus manifestaciones clínicas y diagnóstico dentro del enfoque patológico forense.

Abstract Some of the indications to perform a legal autopsy in Costa Rica, are the sudden deaths as well as judicial inquiries to investigate malpractices causes; in many cases these autopsies are of women in their last pregnancy month or in their post-natal period, specially in the first 5 months. This article search to learn aspects of a specific diagnosis that has to be thought during the forensic analysis of an autopsy of women in the period between the last month of gestation and the first 5 months postpartum: the peripartum cardiomyopathy. This pathology is an unusual kind of dilated cardiomyopathy with a high morbidity and mortality, and so is transcendental to know about it. The goal of this article is to learn about its pathophysiology as well as its clinical manifestations and diagnosis inside the forensic approach.

Practical management of peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy that causes systolic heart failure (HF) in previously healthy young women. Despite latest remarkable achievement, unifying pathophysiologic mechanism is not well established. Considering close temporal relationship to pregnancy, the recent prolactin theory is promising. Abnormal short form of 16-kDa prolactin may be produced in the oxidative stress milieu, show anti-angiogenic effect and damage cardiovascular structure in late pregnancy. Future study is needed to determine whether abnormal prolactin system is useful as a biomarker for diagnosis and therapy of PPCM. Diagnosis is made based on the finding of left ventricular systolic dysfunction after excluding other causes of HF. A multidisciplinary team approach is essential for acute HF, antepartum, labor and postpartum care. Recovery from left ventricular dysfunction is critical for prognosis. As PPCM can recur and cause serious clinical events, subsequent pregnancy is not recommended. This review focuses on the practical management of PPCM.

Evaluation of cardiac ultrasonography in the evaluation of congestive heart failure in peripartum cardiomyopathy patients treated with L-carnitine / 中国生化药物杂志

Objective To evaluate the value of echocardiography in the evaluation of congestive heart failure (PHC) in peripartum cardiomyopathy patients.Methods 64 patients with congestive heart failure were randomly divided into two groups.The control group were treated with routine therapy.The study group were treated with levocarnitine in combination with routine therapy.Echocardiography was performed before and after treatment, and the changes of each index were compared.Results There was no significant difference in left ventricular end diastolic diameter, left ventricular ejection fraction and cardiac output between the two groups before treatment.After treatment, the left ventricular end diastolic diameter, left ventricular ejection fraction and cardiac output in study group after treatment were higher than those in control group(P<0.05).There was no significant difference in left ventricular short axis shortening, left ventricular end-systolic diameter and stroke volume between the two groups before treatment, but the left ventricular short axis shortening and stroke volume in study group after treatment were higher than those in control group (P<0.05), the left ventricular end-systolic diameter was lower ethan that in control group ( P<0.05 ) .The treatment effect of the study group was significantly higher than that in control group (P<0.05).The adverse reactions was significantly lower than that in the control group (P<0.05).Conclusion L-carnitine is effective in the treatment of heart failure in peripartum cardiomyopathy patients.It can be used to evaluate the therapeutic effect of cardiac ultrasound in order to provide guidance for clinical treatment.

Cardiomiopatía periparto / Peripartum Cardiomyopathy

La evolución normal del embarazo, parto o puerperio, puede verse afectada ocasionalmente por la aparición de insuficiencia cardiaca. La mayoría de las veces el origen del síndrome es la presencia de enfermedad cardiovascular previa (conocida o no), y la iatrogenia. El objetivo del trabajo fue presentar una revisión actualizada del concepto, epidemiología, mecanismos fisiopatológicos y estrategias de tratamiento de la cardiomiopatía periparto. Se realizó una revisión actualizada de la literatura internacional sobre el tema. Esta entidad se caracteriza por un síndrome de insuficiencia cardiaca por disfunción sistólica ventricular relacionada con el embarazo. Frecuentemente hace su aparición en el periparto, siendo el especialista en Obstetricia, u otro personal que asiste a la mujer gestante o puérpera quien a menudo tiene el primer contacto con la paciente. Aunque la etiología de la enfermedad es desconocida, nuevas teorías que involucran la predisposición genética, y su relación compleja con la hipófisis, placenta, cardiomiocito y células endoteliales, generan avances en el manejo específico de la enfermedad(AU)

The normal course of pregnancy, childbirth or postpartum, may occasionally be affected by the occurrence of heart failure. Most of the time the origin of this syndrome is the presence of previous cardiovascular disease (known or not), and iatrogenic. The objective of this paper is presenting an updated revision of the concept, its epidemiology, physiopathologic mechanisms and peripartum strategies of treatment of the cardiomyopathy. This entity is characterized by a syndrome of heart failure for systolic ventricular dysfunction related with pregnancy. Frequently it appears in peripartum. The specialist in obstetrics, or other personnel attending to the pregnant or puerperal women, is who often notices of the manifestations of this entity. Although the etiology of this disease is unknown, there are new theories involving genetic predisposition, and complex relationship with the pituitary, placenta, cardiomyocytes and endothelial cells, and generate improvements in this specific disease management(AU)