Stress-Induced Cardiomyopathy Following Cesarean Delivery Under General Anesthesia

Abstract

A 34-year-old non-hypertensive, non-diabetic woman, second gravida, was admitted with 36 weeks' pregnancy complaining of abdominal pain and vaginal bleeding. Apart from the occasional wheeze which promptly settled with inhaled salbutamol, her past history was insignificant. Obstetric examination revealed abruptio placenta with profuse fresh bleeding. She was taken for emergency cesarean surgery under general anesthesia. Her preoperative pulse was 84 bpm, BP 110/80, and her cardiovascular and respiratory systems were normal. Basic investigations were normal including an electrocardiogram (ECG) (Fig. 1). The surgery was uneventful and a male child weighing 3.1 kg was delivered. Intraoperatively, she was given parenteral Glycopyrrolate, Propafol, Suxamethonium, Fentanyl, Inj Syntocin10 U infusion, and Inj. Prostodin 125 mcg intramuscularly. 2 h after surgery, she complained of shortness of breath and left mammary pain. She was dyspneic and mildly desaturated (spO2 88 %). Clinical examination revealed sinus tachycardia (HR 110 bpm), BP of 100/70 mmHg, faint third heart sound, and basal rales over the chest. With a provisional diagnosis of left ventricular failure, ECG, X-ray chest, and Echocardiogram were obtained. The ECG (Fig. 2) revealed subtle changes like loss of ''r'' wave in V2 and the echocardiogram revealed hypokinesia of the mid and apical left ventricle with moderate systolic dysfunction, and her ejection fraction was 38 %. X-ray chest (Fig. 3) showed interstitial edema in the basal zones of both lungs, more on the right. Qualitative troponin T was negative. She was managed with supplemental oxygen, a mild dose of diuretics, dobutamine infusion, and levocarnitine. She responded well, her symptoms abated rapidly, and clinically her lungs became clear and her blood pressure improved. 2 days later, a repeat echocardiogram revealed no wall motion abnormality with normal left ventricular function. DiscussionLeft ventricular failure after cesarean surgery in an apparently healthy woman is rare and could be due to hitherto unrecognized peripartum cardiomyopathy (PPCM) or stress-induced cardiomyopathy (SIC). However, other causes like valvular heart disease, metabolic and endocrine diseases, and rarely acute coronary syndrome should be considered and ruled out. Differentiation of PPCM and stress-induced cardiomyopathy could be difficult in this situation. The following Table lists out the essential differences between PPCM and SIC.