ABSTRACT
A 26-year-old woman in the thirty-second week of her fifth pregnancy was admitted with diffuse sudden-onset abdominal pain. Examination revealed cervical dilation to 8 cm, a ruptured uterine cerclage and transverse presentation of the fetus, indicating a need for emergency cesarean section, which was performed under uneventful spinal anesthesia. Three days after surgery the patient presented signs consistent with acute pulmonary edema coinciding with blood transfusion. Echocardiography demonstrated left ventricular systolic dysfunction with an ejection fraction of 35%. The diagnosis was peripartum myocardiopathy with acute respiratory insufficiency due to heart failure. Furosemide and captopril were prescribed and the outcome was satisfactory. The discharge echocardiogram showed a left ventricle of normal size and thickness, and the ejection fraction was 55%. Peripartum myocardiopathy is a type of heart failure that develops during the third trimester or during the first six months after delivery, in the absence of signs of ventricular dysfunction or previous heart disease. Based on clinical presentation and echocardiographic findings, we believe that peripartum myocardiopathy was the cause of acute pulmonary edema in this patient.
Subject(s)
Cesarean Section , Heart Failure/etiology , Postoperative Complications , Puerperal Disorders , Pulmonary Edema/etiology , Transfusion Reaction , Ventricular Dysfunction, Left/complications , Abdominal Pain/etiology , Acute Disease , Adult , Anemia/complications , Anemia/therapy , Anesthesia, Obstetrical , Anesthesia, Spinal , Blood Volume , Cerclage, Cervical , Emergencies , Female , Fetal Distress/etiology , Heart Failure/diagnostic imaging , Humans , Obstetric Labor Complications , Postoperative Complications/drug therapy , Pregnancy , Pregnancy Complications, Hematologic/therapy , Puerperal Disorders/drug therapy , Pulmonary Edema/drug therapy , Ultrasonography , Uterine Cervical Incompetence/surgery , Ventricular Dysfunction, Left/diagnostic imagingABSTRACT
Una mujer de 26 años, en la semana 32 de su quinta gestación, ingresó por dolor abdominal difuso de instauración brusca. En la exploración se objetivó una dilatación de 8 cm del cuello uterino, rotura del cerclaje uterino y presentación transversa del feto, por lo que se indicó cesárea urgente, que se realizó bajo anestesia subaracnoidea sin incidencias. Al tercer día del postoperatorio la paciente inició un cuadro compatible con edema agudo de pulmón coincidiendo con la administración de sangre. Se le realizó una ecocardiografía que mostró una disfunción sistólica global del ventrículo izquierdo con fracción de eyección del 35 por ciento, y se diagnosticó de miocardiopatía periparto, con insuficiencia respiratoria aguda por insuficiencia cardíaca. Se trató con furosemida y captopril y la evolución fue favorable. Al alta hospitalaria, la ecocardiografía mostró un ventrículo izquierdo de tamaño y espesor normal y fracción de eyección del 55 por ciento. La miocardiopatía periparto es un modo de insuficiencia cardíaca que se produce en el último trimestre de embarazo o durante los seis primeros meses del puerperio, en ausencia de una causa demostrable de disfunción ventricular y de enfermedad cardíaca previa. De acuerdo con la presentación clínica y con los hallazgos ecocardiográficos encontrados en esta paciente, consideramos que la miocardiopatía periparto fue la causa del edema agudo de pulmón (AU)
Subject(s)
Pregnancy , Adult , Female , Humans , Postoperative Complications , Puerperal Disorders , Cesarean Section , Abdominal Pain , Ventricular Dysfunction, Left , Pulmonary Edema , Pregnancy Complications, Hematologic , Cerclage, Cervical , Blood Transfusion , Blood Volume , Acute Disease , Anesthesia, Obstetrical , Anemia , Anesthesia, Spinal , Obstetric Labor Complications , Emergencies , Fetal Distress , Heart Failure , Uterine Cervical IncompetenceABSTRACT
OBJECTIVES: To compare the analgesic efficacy and repercussion on labor of early administration of two different concentrations of bupivacaine/fentanyl in continuous epidural perfusion, in comparison with a control group receiving no epidural anesthesia. PATIENTS AND METHODS: One hundred fifty patients were distributed among 3 groups. Group I (n = 50) received no epidural analgesia. Group II (n = 50) and III (n = 50) received test doses of 3 ml of bupivacaine plus adrenalin 1/200,000. After 5 minutes each patient in the study groups received 13 ml of the solution assigned (group II: 0.04% bupivacaine plus adrenalin 1/2,500,000 and fentanyl 2.5 micrograms/ml; group III: 0.0625% bupivacaine plus adrenalin 1/1,600,000 and fentanyl 2 micrograms/ml). Five minutes later a perfusion of 12 ml/h-1 of the same solution was delivered until dilation was complete. RESULTS: Epidural perfusion was started at 2.5 +/- 0.93 cm of dilation (group II) and 2.3 +/- 0.92 cm (group III). There were no statistically significant differences in either duration of labor until full dilation or expulsion among the groups. Pain assessed on a visual analog scale evolved from a baseline mean of 4.5 to 5 in the three groups, reaching 8.9 +/- 0.74 (group I), 0.24 +/- 0.89 (group II) and 0.28 +/- 0.57 (group III). There were no significant differences in fetal presentation or Apgar scores among the three groups at the end of delivery. CONCLUSION: Both solutions provide good analgesia during labor with minimum undesirable side effects. Low epidural doses of bupivacaine and fentanyl started early do not affect the course of labor.
