Transcript Slide 1

By
Dr/Ramy Ahmed Mahrose
Assistant lecturer of Anesthesia, Intensive Care and Pain
Management
Faculty of Medicine
Ain Shams University
History takings
• 26 years old, Female patient, gravida 2 Para 1
personal
(37 weeks gestation).
data
Past
history
family
history
• Irrelevant.
• Irrelevant.
At the ICU:
The patient presented by
dyspnea and tachypnea,
She is orthopnic.
No paroxysmal nocturnal
dyspnea.
There is no chest pain.
No cough.
No hemoptysis.
By history these symptoms have
developed acutely and
progressively in the previous 2
days.
Her last pregnancy passed
uneventful and delivered a
healthy baby at 40 weeks by
normal vaginal delivery.
Chest examination:
- There was bilateral fine basal crepitation.
Cardiac examination:
- Revealed pan systolic murmur heard at the
apex of the heart.
Abdominal examination:
-The abdominal examination was
unremarkable, the liver and spleen are not
enlarged.
Investigations:
*Laboratory investigations:
- CBC: HB 11gm%, Plt 300,000/ microliter,
WBCs 15000/ microliter.
- Coagulation profile: INR 1.1,PTT 30 seconds.
- Chemistry:BUN 20 mg /dl, s.creat. 0.9 mg/dl
ALT 40 units/litre serum, AST
35
u/LS, s. albumin 2.5 gm./dl, K
3.9 meq/L,
Na 143 meq/L, CK total 90
units/ liter, CKMB 20 units/liter, Troponin negative.
-ABG:
on room air, revealed:
PH:7.46
PO2:62 mmhg.
PCO2:27 mmhg.
HCO3:18 mmole/L
O2Sat.:90%
CXR:
Shows cardiomegaly and some
interstitial lung edema.
Echocardiography(Bed side at ICU):
-Ejection fraction 40%. –No diastolic dysfunction.
-Global hypokinesia.
-Severe mitral regurge.
-Dilated left atrium and ventricle.
-RVSP: 35 mmhg.
Differential diagnoses:
• Many presenting complaints observed
in patients with cardiac disease occur
during a normal pregnancy. Dyspnea,
dizziness, orthopnea, and decreased
exercise capacity often are normal
symptoms in pregnant women. Mild
dyspnea upon exertion is particularly
common in a normal pregnancy.
• The classic dyspnea of pregnancy
is thought to be due to the
progesterone-mediated
hyperventilation. New or rapid
onset of the symptoms requires
prompt evaluation.
- Peripartum cardiomyopathy(PPCM) in
accompany with preeclampsia:
As the patient presented at last month
of pregnancy with impaired left
ventricular systolic function and no
history of underlying cardiac disease,
preeclampsia may be a predisposing
factor for PPCM.
-Preeclampsia complicated by
pulmonary edema:
Hypertension and increased
afterload may lead to heart failure
but this is associated with diastolic
dysfunction and right ventricular
failure more than left ventricular
failure.
-Severe mitral regurge complicated by
heart failure :
But there is no history suggestive of
preexisting cardiac valve disease and
this valve affection may be a
complication of cardiomyopathy and
heart failure.
- Idiopathic dilated cardiomyopathy:
It has clinical characteristics
similar to PPCM but the
onset is not restricted to the
peripartum period and can
occur in the second trimester.
Management:
-Monitoring of the patient using
the standard monitor ( non
invasive blood pressure
measurement ,pulse oximetry
and ECG).
-Establishing intravenous axis
by inserting peripheral cannula
and central venous line.
-Inserting urinary catheter to evaluate
urine output.
-Oxygen therapy : by oxygen mask
6L/min.
- Drug therapy:
#Diuresis was started with intravenous
furosemide shots to decrease the preload
and relieve the congestion.
#Controlling of hypertension using
intravenous nitroglycerin infusion
(0.5-10 mic/kg/min) to decrease the
afterload.
#Magnesium sulfate infusion (1
gm./hour for 24 hours) for
prophylaxis against eclampsia.
#Anticoagulant( Tinzaparin 0.45
ml/day) is important as there is a
high risk of developing
thromboembolic phenomena.
#Pantoprazole (40 mg/24 hour)for
prophylaxis against stress ulcer.
-Delivery of the baby:
#By induction of normal vaginal
delivery which is better than
caesarian section as it is associated
with less bleeding and avoids the
risk of anesthesia.
The patient developed marked
improvement of her condition,
dyspnea improved, the respiratory
rate returned to near normal range,
orthopnea disappeared and chest
became clear by auscultation, blood
pressure became within normal
range, oxygen saturation 95% on
room air, pulse rate 90 bpm.
The patient discharged to ward after 3
days with the following
recommendations:
-Follow up patient vital data.
-Echocardiography( 2 months after
delivery) to follow up the cardiac
condition.
-A low-salt diet was recommended.
-Activities, including nursing the baby,
may be limited when symptoms develop.
-Treatment:
#Diuretics(Furosemide 40 mg tab/24
hr.).
#ACEI(Captopril 25 mg tab/8hr) to
control HTN and decrease afterload.
# Beta blocker (Carvidolol 6.25 mg twice
/day) it has vasodilator effect without
tachycardia also it improve systolic
function and it improves the survival
of patients.