Peripartum cardiomyopathy presenting as splenic infarct

Abstract

A 26-year-old woman presented with a 1-week history of epigastric and left upper quadrant pain associated with nausea and vomiting. She also described 3 weeks of constant substernal chest pain, dyspnea, and decreased exercise tolerance.Her medical history was significant for a pituitary macroadenoma diagnosed 6 years previously that had been treated with cabergoline. She had a miscarriage 7 years ago but gave birth to a healthy child 5 months prior to admission. She had smoked 2 cigarettes per day for the last 7 years. She denied alcohol or illicit drug use. Her mother had sickle cell trait.On admission, her heart rate was 112 beats/minute, blood pressure was 110/80 mm Hg, and respiratory rate was 26 per minute. Jugular venous distension was not appreciated. She had decreased breath sounds over the right lung base. The apical impulse was palpated in the left sixth intercostal space 1 cm lateral to the midclavicular line, and a 2/6 holosystolic murmur was auscultated at the left lower sternal border. No other murmurs or S3 or S4 gallop could be appreciated. There were no vascular or immunological phenomena suggestive of infective endocarditis. She had abdominal tenderness in the epigastrium and bilateral upper quadrants. There was no lower extremity edema, and the extremities were well perfused.Complete blood count, electrolytes, and liver, renal, and coagulation profiles were normal. Her chest x-ray revealed cardiomegaly and bilateral pleural effusions. EKG showed sinus tachycardia and nonspecific T-wave changes. To further evaluate her abdominal pain, a CT scan of the abdomen and pelvis (Fig.1) was ordered. This revealed a 3 by 1.8 cm splenic infarct. Because of her respiratory symptoms and tachycardia, a pulmonary embolism was suspected but was ruled out with a CT angiogram of the chest.She was diagnosed with new-onset heart failure and a splenic infarct. However, it was unclear if the 2 problems were linked. Possible etiologies of the splenic infarct included thrombus from hypercoagulable state (given her prior miscarriage, postpartum state), infarct from hemoglobinopathy (given her family history), septic emboli from infective endocarditis, and peripartum cardiomyopathy associated with embolism to the spleen.Pain control, empiric antibiotics, and intravenous diuretics were started. Twelve hours later, the patient's dyspnea and chest pain resolved. Her blood culture results were negative, and hemoglobin electrophoresis was normal. Results of a hypercoagulable workup for an arterial thrombus that included lupus anticoagulant, anticardiolipin antibodies, and antibodies to ␤2-glycopro- C A S E R E P O R T

Peripartum cardiomyopathy with biventricular thrombus which led to massive cerebral embolism

“…Although acute pulmonary artery thromboembolism was not reported in these 6 cases, it may develop in patients with PPCM and RV thrombus. In PPCM, embolism to cerebral artery, coronary artery, splenic artery, and artery of lower extremity has been reported [21][22][23][24]. Amos et al reported that in 55 patients, the incidence of LV thrombus complicating PPCM was 17%, and only one patient suffered thromboembolism (coronary artery thromboembolism) [14].…”

The Relationship Between Peripartum Cardiomyopathy and Preeclampsia – Pathogenesis, Diagnosis and Management

“…59 Less commonly, PPCM manifests with cardiogenic shock requiring mechanical or inotropic circulatory support or symptomatic or even unstable arrhythmias 60 , 61 and coronary artery thrombosis. 62 …”

Peripartum cardiomyopathy

“…Less commonly, women present with cardiogenic shock that requires inotropic or mechanical circulatory support. Uncommon presentations include symptomatic or even unstable arrhythmias7172 and arterial thromboembolism 7374. Most women present postpartum, mainly during the first month after delivery; a considerable number present in the late antepartum period; and rare cases present as early as the second trimester 66375.…”

“…Thrombosis may occur in both left sided and right sided cardiac chambers 7374101102103104105106107108. Mechanisms underlying intracardiac thrombosis in PPCM include cardiac dilatation and hypocontractability leading to blood stasis, as well as endothelial injury 13.…”