Peripartum and autoimmune cardiomyopathy is an uncommon rare disorder associated with pregnancy. When it occurs association with autoimmune thyroid disorder and autoimmune adrenal insufficiency, it is eponymously referred to as Schmidt syndrome or autoimmune polyendocrine syndrome type 2 (APS type 2). Peripartum cardiomyopathy (PPCM) can be difficult to diagnose as the symptoms can be masked or misinterpreted due to the normal physiological changes during pregnancy, as the symptoms of heart failure can mimic those of pregnancy. PPCM is associated with considerable morbidity and mortality and so should not be underestimated. In this report, we are discussing the management of 32-years-old female with hypothyroidism and Addison’s disease (polyglandular syndrome type 2- Schmidt syndrome) who came for emergency lower segment cesarean section (LSCS) due to twin pregnancy (abnormal doppler of the second twin) and during the period developed pulmonary edema and was diagnosed as peripartum cardiomyopathy.

A 41 year old previously healthy woman (Gravida 4, para 3) was presented to our hospital at 29 weeks gestation, with bleeding Per Vagina (PV) and severe hypertension (190/100). She underwent a routine obstetric examination at 12 weeks gestation and since then she has not undergone any antenatal follow-up. She developed episodes of severe headache, dizziness, sweating, and nausea. She visited a private hospital and was noted to be severely hypertensive (190/120) with headache and palpitations. An ultrasound abdomen was done which showed left suprarenal mass, and a diagnosis of pheochromocytoma was made. She was treated there with antihypertensive medications. When Blood pressure got controlled, she was discharged against medical advice. At 29 weeks, she suddenly developed severe headache and bleeding PV. She visited our centre and was diagnosed to have abruptio-placenta with foetal distress. An emergency caesarean section was done, and following which the patient was treated in the ICU with antihypertensive under invasive monitoring. An MRI demonstrated a left pheochromocytoma. A laparoscopic adrenelectomy was planned later and she got discharged on antihypertensive following an uneventful period of recovery. She got operated later in her country. A laparoscopic left adrenelectomy was done. She is off all medications now and is currently asymptomatic.

A 30-year-old woman (gravida 3, para 1 + 1), with a previous uncomplicated pregnancy and vaginal delivery, was diagnosed with both type 1 Arnold-Chiari malformation and symptomatic multi-level lumbar disc prolapse in her inter-pregnancy period. During this index pregnancy, she experienced progressively worsening occipital headaches radiating to both arms, severe low back pain radiating to both legs and weakness in both legs. She had no urinary or bowel symptoms. She was successfully managed through pregnancy by a multidisciplinary team that included obstetricians, orthopedic and neurosurgeons, obstetric anesthetists and physiotherapists. She had an uncomplicated cesarean delivery under spinal anesthesia. As far as we can tell, this is the first report of both conditions in a pregnant woman.

Inadvertent dural puncture with subsequent post-dural puncture headache (PDPH) is the most typical complication of labour epidural analgesia. Subdural hematoma (SDH) is a rare but late neurological complication of this procedure. The intracranial hypotension created by the cerebrospinal fluid (CSF) leakage through the dural defect can lead to the rupture of the bridging veins to produce a subdural hematoma. A change in the character from postural to a non-postural headache is a warning sign of subdural hematoma. We describe a case of post-dural puncture headache followed by the development of cranial SDH in a patient who refused a blood patch and opted for conservative treatment. We conclude that a high index of suspicion must be maintained with a witnessed dural puncture or even without it but having persistent headache, to detect any severe complications like an intracranial subdural hematoma. An epidural blood patch is to be considered when the headache does not subside with conservative management. Early employment of MRI or CT head imaging studies should be considered to exclude, diagnose, or treat any serious complication without unnecessary delay.

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