ANESTHETIC MANAGEMENT FOR OBSTETRIC CASES WITH IDIOPATHIC PERIPARTUM CARDIOMYOPATHY

Abstract

Peripartum cardiomyopathy is a rare disorder in which left ventricular dysfunction and symptoms of heart failure occur in the peripartum period in previously healthy women. Incidence of PPCM ranges from 1 in 1300 to 1 in 15,000 pregnancies. The etiology of PPCM is unknown, but viral, autoimmune, and idiopathic causes may contribute. The diagnostic criteria are onset of heart failure in the last month of pregnancy or in first 5 months postpartum, absence of determinable cause for cardiac failure, and absence of a demonstrable heart disease before the last month of pregnancy. Risk factors for PPCM include advanced maternal age, multiparity, African race, twinning, gestational hypertension, and long-term tocolysis. PPCM is a diagnosis of exclusion, distinguished by rapid onset, occurrence in the peripartum period, and the significant improvement in up to 50% of affected women. In the past, the diagnosis of this entity was mostly made on clinical grounds, however modern echocardiographic techniques have allowed more accurate diagnoses by excluding cases of diseases that mimic the clinical symptoms and signs of heart failure.

In general, treatment of PPCM is similar to that for other types of congestive heart failure. Current therapeutic options consist of conventional supportive therapy for congestive heart failure, which also involves salt restriction, and the use of diuretics. Hydralazine is the drug of choice prepartum, in addition to nitrates or amlodipine. Angiotensin-converting enzyme inhibitors are the mainstay of treatment post-partum, even in mothers who are breast-feeding. In the acutely ill or highly symptomatic patients, intravenous preload and after-load reducing agents (nitroprusside, nitroglycerin) or inotropic agents (dobutamine, dopamine, milrinone) should be considered.