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An unusual case of peripartum cardiomyopathy manifesting with multiple thrombo-embolic phenomena.

Ibebuogu UN, Thornton JW, Reed GL - Thromb J (2007)

Bottom Line: Onset is usually between the last month of pregnancy and up to 5 months postpartum in previously healthy women.PPCM initially presents with signs and symptoms of congestive heart failure and rarely with thrombo-embolic complications.This case illustrates that abdominal pain in PPCM may not always result from hepatic congestion as previously reported, but may occur as a result of thromboemboli to abdominal organs.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Cardiology, Medical College of Georgia, Augusta, Georgia, USA. ibebuogu@yahoo.com.

ABSTRACT
Peripartum cardiomyopathy (PPCM) is a rare form of heart failure with a reported incidence of 1 per 3000 to 1 per 4000 live births and a fatality rate of 20%-50%. Onset is usually between the last month of pregnancy and up to 5 months postpartum in previously healthy women. Although viral, autoimmune and idiopathic factors may be contributory, its etiology remains unknown. PPCM initially presents with signs and symptoms of congestive heart failure and rarely with thrombo-embolic complications. We report an unusual case of PPCM in a previously healthy postpartum woman who presented with an acute abdomen due to unrecognized thromboemboli of the abdominal organs. This case illustrates that abdominal pain in PPCM may not always result from hepatic congestion as previously reported, but may occur as a result of thromboemboli to abdominal organs. Further research is needed to determine the true incidence of thromboemboli in PPCM.

No MeSH data available.


Related in: MedlinePlus

Computed tomography scan showing biventricular thrombi (white arrow) and a low attenuation lesion in the right lobe of the liver (black arrow).
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Figure 4: Computed tomography scan showing biventricular thrombi (white arrow) and a low attenuation lesion in the right lobe of the liver (black arrow).

Mentions: A 24 year old gravida 5 woman with no history of alcohol or drug abuse, and no previous history of cardiovascular disease, presented to the emergency department (ED) 5 months after an uneventful full term spontaneous vaginal delivery followed by tubal ligation. She complained of a severe epigastric and right upper quadrant abdominal pain, nausea and vomiting. Physical examination revealed normal vital signs, epigastric and right upper quadrant tenderness without peritoneal signs. Abdominal ultrasound showed thickened anterior gall bladder wall without stones or sludge and no pericholecystic fluid. Liver enzymes and amylase were within normal limits. She was given analgesics and subsequently discharged from the ED following complete resolution of her symptoms. Three days later she returned with a severe, worsening right upper quadrant and epigatric pain, nausea and shortness of breath. She also complained of left lower extremity and back pains. At this time, her blood pressure was 130/100 mmHg with a heart rate of 100. She had bilaterally decreased air entry on lung examination, intermittent apical third heart sound with a regular rate and rhythm, right upper quadrant and epigastric tenderness, bilateral costovertebral angle tenderness and a negative Murphy's sign. An acute abdominal x-ray series was normal. Chest x-ray (Fig. 1) showed moderate cardiomegaly and prominent bibasilar interstitial markings. Electrocardiography (Fig. 2) revealed a normal axis with diffuse T-wave inversion. A transthoracic echocardiography (TTE) (Fig. 3) revealed biventricular dilatation with a left ventricular end-diastolic dimension of 65 mm, a depressed fractional shortening of 9%, an ejection fraction of <15% and a left ventricular anterior wall thrombus. The patient was diagnosed with peripartum cardiomyopathy with congestive heart failure, liver congestion and a left ventricular mural thrombus. She was placed on bed rest with telemetry monitoring and started on therapeutic dose of low molecular weight heparin, nitrates, diuretics and an ACE inhibitor. Although, her congestive heart failure symptoms improved, her abdominal pain worsened. She had elevated lactic acid level (3.3 mmol/L) and white cell count (12,200/mm3), with no evidence of liver congestion on imaging. Right heart catheterization revealed normal cardiac output and right heart pressures with no evidence of intracardiac shunt, and a cardiac index of 2.6 L/min/m2. Computed tomography (CT) scan revealed findings suggestive of a biventricular thrombi and an 8 mm low attenuation lesion at the dome of the right lobe of the liver (Fig. 4), multiple wedge defects in both kidneys (Fig. 5), and a partially occlusive thrombus within the common iliac and right external iliac arteries. An arteriogram subsequently confirmed bilateral iliac and superficial femoral artery thrombi. Assays for IgG and IgM anticardiolipin antibodies were negative (6.8 GPL and <4.0 MPL respectively), and rheumatoid factor was less than 20 IU/mL. HIV I and II, hepatitis B and C, and RPR, were all negative and her ferritin level was within normal limits. She underwent successful bilateral lower extremity thrombectomies. Her renal function remained stable throughout her admission. She improved clinically on anticoagulation and heart failure therapy and repeat TTE 5 days after she presented showed no evidence of thrombi in either ventricle. Her lactic acid levels normalized on day 6 of hospitalization and she was discharged 2 weeks after she presented with follow up in the outpatient cardiology clinic.


An unusual case of peripartum cardiomyopathy manifesting with multiple thrombo-embolic phenomena.

Ibebuogu UN, Thornton JW, Reed GL - Thromb J (2007)

Computed tomography scan showing biventricular thrombi (white arrow) and a low attenuation lesion in the right lobe of the liver (black arrow).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2169208&req=5

Figure 4: Computed tomography scan showing biventricular thrombi (white arrow) and a low attenuation lesion in the right lobe of the liver (black arrow).
Mentions: A 24 year old gravida 5 woman with no history of alcohol or drug abuse, and no previous history of cardiovascular disease, presented to the emergency department (ED) 5 months after an uneventful full term spontaneous vaginal delivery followed by tubal ligation. She complained of a severe epigastric and right upper quadrant abdominal pain, nausea and vomiting. Physical examination revealed normal vital signs, epigastric and right upper quadrant tenderness without peritoneal signs. Abdominal ultrasound showed thickened anterior gall bladder wall without stones or sludge and no pericholecystic fluid. Liver enzymes and amylase were within normal limits. She was given analgesics and subsequently discharged from the ED following complete resolution of her symptoms. Three days later she returned with a severe, worsening right upper quadrant and epigatric pain, nausea and shortness of breath. She also complained of left lower extremity and back pains. At this time, her blood pressure was 130/100 mmHg with a heart rate of 100. She had bilaterally decreased air entry on lung examination, intermittent apical third heart sound with a regular rate and rhythm, right upper quadrant and epigastric tenderness, bilateral costovertebral angle tenderness and a negative Murphy's sign. An acute abdominal x-ray series was normal. Chest x-ray (Fig. 1) showed moderate cardiomegaly and prominent bibasilar interstitial markings. Electrocardiography (Fig. 2) revealed a normal axis with diffuse T-wave inversion. A transthoracic echocardiography (TTE) (Fig. 3) revealed biventricular dilatation with a left ventricular end-diastolic dimension of 65 mm, a depressed fractional shortening of 9%, an ejection fraction of <15% and a left ventricular anterior wall thrombus. The patient was diagnosed with peripartum cardiomyopathy with congestive heart failure, liver congestion and a left ventricular mural thrombus. She was placed on bed rest with telemetry monitoring and started on therapeutic dose of low molecular weight heparin, nitrates, diuretics and an ACE inhibitor. Although, her congestive heart failure symptoms improved, her abdominal pain worsened. She had elevated lactic acid level (3.3 mmol/L) and white cell count (12,200/mm3), with no evidence of liver congestion on imaging. Right heart catheterization revealed normal cardiac output and right heart pressures with no evidence of intracardiac shunt, and a cardiac index of 2.6 L/min/m2. Computed tomography (CT) scan revealed findings suggestive of a biventricular thrombi and an 8 mm low attenuation lesion at the dome of the right lobe of the liver (Fig. 4), multiple wedge defects in both kidneys (Fig. 5), and a partially occlusive thrombus within the common iliac and right external iliac arteries. An arteriogram subsequently confirmed bilateral iliac and superficial femoral artery thrombi. Assays for IgG and IgM anticardiolipin antibodies were negative (6.8 GPL and <4.0 MPL respectively), and rheumatoid factor was less than 20 IU/mL. HIV I and II, hepatitis B and C, and RPR, were all negative and her ferritin level was within normal limits. She underwent successful bilateral lower extremity thrombectomies. Her renal function remained stable throughout her admission. She improved clinically on anticoagulation and heart failure therapy and repeat TTE 5 days after she presented showed no evidence of thrombi in either ventricle. Her lactic acid levels normalized on day 6 of hospitalization and she was discharged 2 weeks after she presented with follow up in the outpatient cardiology clinic.

Bottom Line: Onset is usually between the last month of pregnancy and up to 5 months postpartum in previously healthy women.PPCM initially presents with signs and symptoms of congestive heart failure and rarely with thrombo-embolic complications.This case illustrates that abdominal pain in PPCM may not always result from hepatic congestion as previously reported, but may occur as a result of thromboemboli to abdominal organs.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Cardiology, Medical College of Georgia, Augusta, Georgia, USA. ibebuogu@yahoo.com.

ABSTRACT
Peripartum cardiomyopathy (PPCM) is a rare form of heart failure with a reported incidence of 1 per 3000 to 1 per 4000 live births and a fatality rate of 20%-50%. Onset is usually between the last month of pregnancy and up to 5 months postpartum in previously healthy women. Although viral, autoimmune and idiopathic factors may be contributory, its etiology remains unknown. PPCM initially presents with signs and symptoms of congestive heart failure and rarely with thrombo-embolic complications. We report an unusual case of PPCM in a previously healthy postpartum woman who presented with an acute abdomen due to unrecognized thromboemboli of the abdominal organs. This case illustrates that abdominal pain in PPCM may not always result from hepatic congestion as previously reported, but may occur as a result of thromboemboli to abdominal organs. Further research is needed to determine the true incidence of thromboemboli in PPCM.

No MeSH data available.


Related in: MedlinePlus