SummaryA case of peripartum cardiomyopathy that occurred together with pre-eclampsia is described. This gave rise to pulmonary oedema at 36 weeks' gestation. Intensive care management and the need for invasive monitoring, especially pulmonary artery wedge pressure, of patients who develop pulmonary oedema in the peripartum period is discussed.
Key wordsComplications; peripartum cardiomyopathy.Cardiomyopathy of pregnancy, or peripartum cardiomyopathy, is a rare condition which presents clinically with the onset of cardiac failure in the last month of pregnancy, or the first 5 postpartum months. There should be no obvious aetiology for the cardiac failure and no evidence of demonstrable heart disease before the last month of pregnancy.'"The diagnosis becomes confused and therapeutic efforts may be misdirected when pre-eclampsia occurs together with peripartum cardiomyopathy. We describe such a patient who required intensive care management.
Case historyA 23-year-old Caucasian primigravida was admitted to a District General Hospital at 36 weeks' gestation because of marked peripheral oedema and proteinuria of 3 g/24 hours. She was known to have a fetus with an abdominal wall defect, and for this reason was booked into the regional paediatric referral centre for delivery. Her arterial blood pressure did not increase initially, but she was noted to be anaemic.She complained of tightness in her chest the day after admission. Her blood pressure was 150j85 mmHg and heart rate 130 beats/minute on examination, but her chest was clear on auscultation. That night her membranes ruptured spontaneously, so she was transferred to the regional centre with an infusion of ritodrine as a tocolytic agent.On arrival, her arterial pressure was 140/95 mmHg; she had 2+ proteinuria, and a diagnosis of mild to moderate pre-eclampsia was made. A lumbar epidural catheter was inserted and 0.25% bupivacaine 8 ml administered. She also received approximately 1500 ml crystalloid intravenously. She complained of shortness of breath and chest pain one hour later. On examination, her arterial blood pressure was 160/110 mmHg, heart rate 140 beats/minute and bilateral basal crepitations were present. A chest X ray confirmed pulmonary oedema and she was given frusemide intravenously.A decision to perform urgent Caesarean section was then made. A central venous line was inserted via an antecubital vein and its position confirmed on X ray. This gave an initial reading of zero (referred to right atrium). Caesarean section was performed under general anaesthesia and a live male infant who weighed 3180 g, with the expected gastroschisis, was delivered. There were no intra-operative problems and on recovery her blood pressure was 15OjllO mmHg, central venous pressure (CVP) 4 cm H,O, heart rate 110 beats/minute and respiratory rate 32 breaths/ minute. A good diuresis occurred in response to frusemide and this was followed by clinical improvement. However, the basal crepitations persisted.She suffered an exacerbation of her pulmonary oedema during the night;...
