Peripartum cardiomyopathy is one of the leading causes of death in obstetric patients since it is usually diagnosed incidentally. Echocardiogram remains the mainstay to diagnose it. Many of the peripheral hospitals are deficient of echocardiogram facilities, so there are possibilities to send the patient to OR without diagnosis. To manage such a case and bring out the success depends on quick detection of the problems & immediate medical intervention after confirming the diagnosis. Obviously, any surgical intervention requires lot of clinical experiences of the whole team, particularly the anesthesiologists.

3.  Name : Nilufa Yasmin
 Spouse : W/O L/Cpl Sufian
 Age : 22 years
 Gender : Female
 Religion : Islam
 Marital Status : Married
 Hailing from : Rohanpur,Chapainawabgonj .
 Date of Admission : 16th May 2017
Particulars of the Patient

4.  Amenorrhoea due to pregnancy for
37+ weeks
 Shortness of breath and cough for
2 days.
 Palpitation for 2 days.
Chief complaints

5. The patient was amenorrhoeic for 37+ weeks and
developed shortness of breath, cough and palpitation
for last two days. Palpitation and breathlessness
appeared while performing ordinary household activity
which use to aggravate in lying position and relieved by
taking rest. Her cough was productive and sputum was
frothy. She also observed fluid retention in both legs for
few weeks. With gradual deterioration of her symptoms
she got admitted to CMH Dhaka.
H/OPresent illness

6. H/OPast illness
 No H/O of HTN, DM, Bronchial Asthma,
Rheumatic Fever or other illness.
 Nothing Contributory.
Family History

7.  The patient was on iron, vitamin B complex &
calcium supplementation during her pregnancy.
She was on regular antenatal check up.
Treatment History
 Low middle class family
Socio-economic History

8. Married for : 2 years
Para : 0
Gravida : Primi
Obstetric History
Menstrual cycle : Regular
LMP : 26 August 2016
EDD : 02 June 2017
Menstrual History

9.  Appearance :
 Built : Average
 Nutritional status : Average
 Decubitus : Propped up
 Anaemia :
 Edema :
 Pulse : 120 b/min
 BP : 90/60 mm Hg
 Temperature : 99˚F
 Respiratory rate : 25/min
General Examination

10. Systemic Examination
Inspection Palpation Percussion Auscultation
 Shape :Normal
 Chest
movement:
symmetrical on
both side
 No visible scar
mark
 No visible
engorged vein
 Respiratory
rate: 20 b/min
 Trachea:
centrally placed
 Apex beat:
normal
 Chest
expansibility:
symmetrical on
both side
 Vocal fremitus:
normal
 Percussion:
Resonant
 Cardiac
dullness:
Normal
 Vesicular
breath
sound and
basal
crepitation
present on
both lung
field.

11. Systemic Examination(Continued)
Nothing abnormality detected
Inspection Palpation Auscultation
 JVP: Raised  Apex beat: Left 5th
intercostal space
 Thrill: Absent
 1st and 2nd heart
sound: Normal in all
areas
 No added sound
No abnormality

12. Inspection Palpation Auscultation
 Pyriform in
shape
 Umbilicus:
Centrally
placed
Symphysio fundal height:
Reveals 36 weeks of pregnancy
Abdominal girth : 100 cm
Foetal movement: present
Fundal grip :head felt
Lateral grip :back felt on
right side and the limbs on the left
side and foetal parts are easily
palpable
 Fetal heart
rate: 144
beat/min
local Examination
No active P/V bleeding

13. Salient Features
Mrs Nilufa Yasmin, Age = 22 years, a primigravida
of 37+ weeks admitted to CMH Dhaka with
shortness of breath, productive cough and palpitation
for two days which aggravated with lying and
relieved by taking rest. She was mildly dyspnoeic
and peripheral edema was present in both the legs.
Her pulse rate was 120 beats/min, BP- 90/60 mmHg
and respiratory rate was 25 breaths/min.

14. Salient Features(Continued)
On systemic examination, JVP found raised and there
was bilateral basal crepitation. Per abdominal
examination revealed that size of her uterus was
corresponding to 36 weeks of gestation with cephalic
presentation, foetal heart rate was 144 beats/min. She
was on regular antenatal checkup and her antenatal
period was uneventful up to appearance of these
symptoms.

15. clinical diagnosis
A case of 37+ weeks pregnancy with
Left ventricular failure

16. Investigations
 Hb conc. : 11.20 gm/dl
 Total Red Blood cells : 3.87×1012/L
 Hct : 33.90%
 Total White blood cells : 8.70×109/L
 Differential Leucocyte count :
 Neutrophils - 81%
 Eosinophils - 01%
 Basophils - 00%
 Lymphocytes - 14%
 Monocytes - 04%
 Others - 00%

17. Platelets : 250.00×109/L
ESR (Westergren) : 20 mm in 1st hour
Prothrombin Time (PT):
Patient : 14 second
Control : 13 second
INR : 1.10
Activated Partial Thromboplastin Time (APTT):
Patient : 31 second
Control : 31 second
Investigations (Continued)

18. Investigations (Continued)
Serum Sodium (Na) : 135 mmol/L
Serum Potassium (K) : 4.4 mmol/L
Serum Chloride (CL) : 95 mmol/L
Serum Urea : 26 mg/dl
Serum Creatinine 0.5 mg/dl
Serum CK-MB : 9 U/L
 Plasma Glucose (Fasting) : 5.1 mmol/L

19.  Sinus Tachycardia
 O (+ve)
Not done
Investigations (Continued)

20. Physical and Chemical
examination
Microscopic
Examination
Appearance:
Sp. Gravity:
Reaction:
Protein:
Glucose:
Bile salt:
Bile
pigments:
Light amber
Not done
Acidic
Nil
Nil
Not done
Not done
WBCs:
RBCs:
Epithelial
cells:
Casts:
Crystals:
Others:
1-2/HPF
Nil/HPF
4-6/HPF
Nil
Nil
Nil
Investigations (Continued)

21.  Uterus was gravid containing single live foetus with
regular cardiac pulsations and normal foetal movement
 Foetal presentation: cephalic
 Placenta: Fundal & posterior
in position & away from os
 Gestational age: 37+ weeks
Investigations (Continued)

22. Borderline LV & LA dilatation
Global hypokinesia of LV
Moderate to severe LV systolic
dysfunction (EF = 40%)
Mild MR
Peripartum Dilated
Cardiomyopathy
Investigations (Continued)

23. final diagnosis
A case of 37+ weeks pregnancy with
peripartum cardiomyopathy

24. Obstetric plan

25. Anaestheticmanagement

26. PRE ANAESTHETIC ASSESSMENT
Pre-anaesthetic check-up was done with detailed
history, proper clinical examination and
assessment of the investigation reports.

27. PRE ANAESTHETIC ASSESSMENT
Procedure was explained to
the patient and her attendant.
Informed written consent was
obtained for operation and
anaesthesia .

28. ANAESTHETICPLAN
Normally lower uterine caesarean section (LUCS) is
done under Subarachnoid block (SAB), which blocks
the sympathetic nervous system of lower half of the
body that causes peripheral vasodilation followed by
hypotension. This is usually managed by rapid fluid
administration and peripheral vasoconstrictor drugs.
As the patient was suffering from peripartum
cardiomyopathy with EF 40%, so her heart would not
be able to handle excessive fluid load and increased
peripheral vascular resistance.

29. ANAESTHETICPLAN
 Patient was diagnosed as a case
of peripartum cardiomyopathy
with moderate left ventricular
dysfunction, so surgery was
planned to perform under general
anaesthesia.

30. Anticipated Challenges DURING general
ANAESTHESIA
 Difficulties in intubation
 Avoidance of both tachycardia and bradycardia
 Wide ranges of hemodynamic instability
 Maintenance of vital organ perfusion
 Avoidance of negative inotropic agents
 Prevention of increase in afterload
 Expected blood loss & challenges of resuscitation

31. Airway management
equipment
Different sized ET
tube
Gum elastic bougie
Breathing circuits
Syringe pumps with
medication
Drugs for GA and
emergency carts.
Preparationfor Anaesthesia

32. Defibrillator was kept ready to
combat possibility of incidental
arrhythmias
Large-bore 16 gauze I/V line was
established through left cephalic
vein
2 units of blood
Urinary catheterization was done
Paediatric team was ready in the
operation theater.
Preparation for Anaesthesia (Continued)

33. A 20 cm, 7 Fr. central
venous catheter was
established through
right internal jugular
vein to access the
central compartment
of cardiovascular
system.
Preparation for Anaesthesia (Continued)

34. An intra-arterial line
was established in
right radial artery to
monitor continuous
beat to beat accurate
real time all ranges
of blood pressure
measure from zero to
any level.
Preparation for Anaesthesia (Continued)

35. Inj. Omeprazole 40 mg
Inj. Ondansetron 8 mg
Premedication
Medications given on the OT table before operation

36. Induction was done by Inj.
Propofol.
Intubation was done after
adequate muscle relaxation
with Inj. Suxamethonium.
Induction and Intubation

37. Anaesthesia was maintained with O2 60% and N2O
40%.
Adequate analgesia was ensured with intravenous
Fentanyl (100 mcg) after delivery to avoid fetal
respiratory depression as narcotics cross the placental
barrier.
Adequate muscle relaxation was provided with
intermittent NMBA (Inj. Vecuronium Bromide 5mg).
Maintenance OF ANAESTHESIA

38. Routine monitoring
of ECG and SpO2
Continuous EtCO2
was monitored and
kept below 30 mmHg
ABG analysis was
done and correction
was given according
to the report
Intra-operative monitoring

39. MANAGEMENT OF HAEMODYNAMICS DURING
ANAESTHESIA
Infusion of fluid judiciously by measuring CVP
because dilated LV would not be able to handle fluid
over load.
Hypotension usually manage by large volume of fluid
infusion and peripheral vasoconstrictor. Both are
detrimental for this patient. We manage the incidence
of hypotension by inotropes.

40.  During surgery there were incidence of unusual
tachycardia that is manage by Inj Esmolol IV.
 Balance between fluid infusion & urine output to
keep the lung dry.
 Adequate analgesic was administer to make the
patient stress free.
MANAGEMENT OF HAEMODYNAMICS DURING
ANAESTHESIA (Continued)

41. Baby resuscitation
 A female baby of 2.7 kg body
weight, APGAR score =10 was
delivered at 1040 hours by
LUCS.
 Immediate resuscitation of the
newborn carried out at the
operation theater by the
attending paediatric team.

42. Reversal from general anaesthesia is a very crucial
phenomenon. so compromised patient may not be able
to compensate the conventional reversal. Moreover, this
patient needed a less stress and pain free reversal. So she
was not reversed on the operation theater and shifted to
critical care center for intensive monitoring. On 3rd post
operative day she was extubated uneventfully.
Issue of Reversal

43. Discussion

44. cardiomyopathy
 Disease of the heart muscle in which the heart loses
its ability to pump blood effectively.
 The heart muscle becomes enlarged or abnormally
thick or rigid.
 In rare cases, the muscle tissue in the heart is
replaced with scar tissue.
 As cardiomyopathy progresses the heart becomes
weaker and less able to pump blood through the body
leads to heart failure, arrhythmias, systemic and
pulmonary edema and more rarely endocarditis.

45. classification
Cardiomyopathy may
be categorized in to
main three groups:
 Hypertrophic
cardiomyopathy
 Dilated
cardiomyopathy
 Restrictive
cardiomyopathy

46. Ppcm
PERIPARTUMCARDIOMYOPATHY(ppcm)
 Peripartum cardiomyopathy is
defined as the onset of acute heart
failure without demonstrable
cause in the last trimester of
pregnancy or within the first 5
months after delivery of baby.
 A form of Dilated
Cardiomyopathy leading to left
ventricular systolic dysfunction
resulting in signs and symptoms
of heart failure.

47. INCIDENCE
 The incidence in the West ranges from 1 in 4000
deliveries.
 60% present within the first 2 months of postpartum
period.
 Up to 7% may present in the last trimester of
pregnancy.
 Geographical variations exist with a higher incidence
reported in areas of Africa because of malnutrition and
local customs in the puerperium.
INCIDENCE

48. High risk factors
MULTIPARITY
Increased maternal age (>35 yrs)
H/O previous C/S or scar in the uterus
 ( myomectomy/ hysterotomy)
Placental size and abnormality
smoking
Prior curettage

49. Management of ppcm
The objective of peripartum
cardiomyopathy management is to
reduce extra fluid from the lung and
to help the heart recover as fully as
possible.
Diuretics
ß-blockers
Digoxin
Anticoagulant

50. Management of ppcm
Spontaneous vaginal delivery at
term is reasonable unless mother is
decompensating.
Painless and effortless
labor/delivery
Elective lower uterine caesarean
section if patient present with
obstetric complication.

51. Choice of anaesthesia
 Normal vaginal delivery is
mostly expected. But in any
case if patient requires
anaesthesia, it should be
usually general anaethesia.
 Other modes of anaesthesia
may be epidural anaesthesia
or combined spinal epidural
(CSE)

52. General anaesthesia
 For a handsome control of all the
systems of body general anaesthesia
is prefered.
 Opioid based anaesthesia provides
good haemodynamic control &
obtundation of response to
endotracheal intubation.

53. Epidural anaesthesia OR CombinedSPINAL-
EDIDURAL(cse)
In situations like full stomach where
introduction of general anaesthesia
may be hazardous to the patient then
epidural anaesthesia may be a good
alternative.
Because epidural anaesthesia
involves minimum haemodynamic
instability & it causes desirable
decrease in afterload.

54. Prognosis of ppcm
50-60% patients show complete or near complete
recovery within the first 6 months of postpartum
period.
In others, either continued clinical deterioration
leading to early death or persistent left ventricular
dysfunction and chronic heart failure.
There is an initial high risk period with mortality of
25-50% in the first 3 months of postpartum period.
Patients with persistent cardiomegaly at 6 months
have a reported mortality of 85% at 5 years

55. Conclusion
Peripartum cardiomyopathy is one of the leading causes of
death in obstetric patients since it is usually diagnosed
incidentally. Echocardiogram remains the mainstay to
diagnose. Many of the peripheral hospitals are deficient of
echocardiogram, so there are possibilities to send the
patient to OR without diagnosis. To manage such a case
and bring out the success depends on quick detection of
the problems & immediate medical intervention after
confirming the diagnosis. Obviously, any surgical
intervention requires lot of clinical experiences of the
whole team, particularly anaesthesiologist.