Mrs. Sumoti Rani, a 35-year old teacher from Sunamganj, is admitted at 37+6 weeks of her third pregnancy. She has a history of peripartum cardiomyopathy and chronic hypertension over the past 10 years. On examination, she has mild anemia but her cardiovascular and respiratory examinations are normal. She is not in labor and has good exercise tolerance while being treated for her medical conditions. Close monitoring is planned due to her medical history and late stage of high-risk pregnancy.

1. Dr Namkha Dorji
Resident (Phase B)
Department of Obstetrics & Gynaecology
Bangabandhu Sheikh Mujib Medical University
Dhaka, Bangladesh
Case Presentation
10/29/20151 Dr Namkha Dorji,Resident, OBGYN, BSMMU

2. Patient’s particulars:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU2
 Name: Mrs Sumoti Rani
 Age: 35 year
 Address: Sunamganj
 Bed: FM 17
 Ward: 8A
 Unit: Red
 DoA: 14th October, 2015
 History on: 14th October, 2015

3. Presenting complaints:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU3
 Pregnancy for 37+6 weeks
 History of heart disease and hypertension for 10 years

4. History of presenting complaints:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU4
 Diagnosed heart disease and hypertension- 10 years
 Planned pregnancy
 No preconceptional counselling
 LMP: 22/01/2015
 EDD: 29/10/2015
 Regular ANC visit
 Uneventful T1 & T2: normal routine investigations.
 T3: one episode of breathing difficulties
: managed conservatively
Gravida : 3
Para: 2 + 0
P1: NVD & P2: LUCS
ALC; 4 years
Corresponds with
early USG EDD

5. 10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU5
Fetal movement good
Good exercise tolerance
Admitted for confinement

6. Past obstetrics history:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU6
Uneventful ANC NVD at Sylhet Osmani
Medical College Female
3.5 kg
Unventful puerperum upto
4 months.
At 4 months: paroxysmal
nocturnal dyspnoe
Diagnosed as DCM (EF
32%) and Hypertension
First
Pregnancy
(2005)

7. Second pregnancy (2011)
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU7
ANC
uneventful
LUCS
at Sylhet OsmaniMedical
college
Female ? Birth weight
Uneventful postpartum period: no ICU
care or Heart failure

8. Past medical history:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU8
DCM & hypertension (since 2005)
on regular follow up
asymptomatic on Tab. Angilock
(25/100) daily one tab

9. Past surgical history:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU9
 Tonsillectomy ( about 20 years back)
 LUCS under SA ( in 2011)
No post operative complications: anesthesia
or surgical related.

10. Drugs history:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU10
In addition to routine vitamins supplement:
Tab. Furosemide 10mg OD
Tab. Labetalol 100mg BD
Tab. Methyl Dopa 250 mg BD
No significant side effects

11. Family History:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU11
• Developed DCM after
P3
First sister
• Developed DCM after
P1
Third sister

12. Social History:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU12
 Teacher
 Husband is Government service holder
 Smoker
 Good family support

13. 10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU13

14. General examination:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU14
Not dyspneoic
Mild pallor
No cyanosis
No thyroid enlargement or engorged neck vein
No ankle oedema
PR: 80 b/m, regular rhythm and good volume
BP: 140/80 mmHg

15. Cardiovascular system:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU15
Apex beat: 5th ICS in left midclavicular line.
No added sounds or murmur

16. Respiratory system:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU16
Equal Air entry
Vesicular breath sound
No crepitation in the bilateral lung bases

17. Obstetric examination:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU17
 Well healed previous pfannenstiel scar
 Fundal height: 36 weeks
 Longitudinal lie
 Left occipito anterior position
 Cephalic presentation
 Head not engaged
 Liquour: adequate
 EFW: 3000 grams
 FHS: 148 bpm
 No scar tenderness

18. 10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU18
P/V/E
NOT DONE

19. Clinical Diagnosis:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU19
Third gravida at 37+6 weeks pregnancy with peripartum
cardiomyopathy( NYHA grade I) and chronic essential
hypertension with history of previous one LUCS

20. Discussion period:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU20

21. 10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU21

22. Summary:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU22
 Mrs Sumoti Rani, 35 year, from Sunamganj, mother of
two children(P1:NVD & P2:LUCS) in her third pregnancy is
admitted at 37+6 week. She is a diagnosed patient with
peripatum cardiomyopathy and chronic essential
hypertension for last 10 years on drugs. Her exercise
tolerance is good and she is not in labour. Her two
sisters as well has perpartum cardiomyopathy.
 Other than mild anemia, there is no significant findings
on general, Respiratory system and cardivascular
examination. On obstetric exam, fundal height
corresponds to 36 weeks with cephalic presenation and
longitudinal lie. Liquour is adequate and FHS present.
There is no scar tenderness.

23. Outdoor management:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU23

24. In ward care:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU24
Multidisciplinary team approach
• Obstetrician
• Cardiologist
• Anesthesiologist
• Neonatologist
• ??? Husband & her relatives

25. Plans on admission:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU25

26. Management:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU26
 Counselling
 Cardiology opinion
 Anesthesia opinion
 ICU/NICU/CCU
 Antibiotic prophylaxis
 Epidural anesthesia/analgesia + systemic angesics
 Controlled I/V fluid administration
 BLTL done
 Very close monitoring

27. 10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU27

28. 10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU28

29. 10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU29

30. 10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU30

31. 10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU31

32. 10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU32

33. PPCM
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU33
 Incidence: 1:300 to 1:4000 pregnancies
 Postpartum cardiomyopathy or puerperal heart
failure
 Peripartum cardiomyopathy: symptoms & signs of
this disease may appear at any time in the last
month of pregancy and up to 5 months after
delivery.

34. Risk Factors:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU34
 Advanced maternal age
 Multiparity
 Multifetal gestation
 Obesity
 Black race

35. Criteria for diagnosis:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU35
 Development of heart failure in the last month of
pregnancy or up to 5 months postpartum
 Absence of an identifiable cause for heart failure
 No recognisable heart disease before the last month of
pregnancy
 Left ventricular systolic dysfunction shown by
echocardiographic criteria.

36. Symptoms:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU36
 Weakness
 Shortness of breath
 Orthopnoea
 Cough
 Paroxysmal nocturnal dyspnoe
 palpitations

37. Signs:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU37
 Tachycardia
 Cardiac arrhythmias
 Pulmonary crepitations
 Peripheral oedema

38. Investigations:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU38
 CXR: enlarged heart & pulmonary vascular distribution
 Echo & right heart catheterization: enlargement of all
chambers of the heart, predominantly left ventricle. LV
EF & CO are decreased & pulmonary wedge pressure is
increased.
 Thrombosis & PE

39. Management:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU39
 Bed rest
 Digitalis
 Diuretics
 Anticoagulants
 Immunosuppressant therapy- not recommended

40. Prognosis:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU40
 High mortality- dilated heart 6 months after the initiation
of therapy
 Good prognosis- normal sized heart 6 months after the
initiation of therapy
 Poor- treatment initiated 6 months after the onset of
symptoms

41. Recurrence:
10/29/2015Dr Namkha Dorji,Resident, OBGYN, BSMMU41
 21 % in women whose LV function returned to
normal
 44 % in persistent LV dysfunction