A 34-year-old woman, gravida 1 para 0, comes to the office at 38 weeks gestation due to increasing shortness of breath. The patient says that the pregnancy is causing too much discomfort and requests delivery. She cannot find a comfortable position to sleep in, and after walking several steps she needs to stop to catch her breath. The patient's pregnancy has been uncomplicated, and she has no significant medical conditions. She does not use tobacco or alcohol. Blood pressure is 132/85 mm Hg and pulse is 112/min and regular. An S3 is present on cardiac auscultation. A new grade III/VI holosystolic murmur is heard at the apex. Pitting edema is present over the lower extremities to just below the knees. Urinalysis shows trace protein. ECG demonstrates sinus tachycardia. Which of the following is the best next step in management of this patient?

Question

A 34-year-old woman, gravida 1 para 0, comes to the office at 38 weeks gestation due to increasing shortness of breath.  The patient says that the pregnancy is causing too much discomfort and requests delivery.  She cannot find a comfortable position to sleep in, and after walking several steps she needs to stop to catch her breath.  The patient's pregnancy has been uncomplicated, and she has no significant medical conditions.  She does not use tobacco or alcohol.  Blood pressure is 132/85 mm Hg and pulse is 112/min and regular.  An S3 is present on cardiac auscultation.  A new grade III/VI holosystolic murmur is heard at the apex.  Pitting edema is present over the lower extremities to just below the knees.  Urinalysis shows trace protein.  ECG demonstrates sinus tachycardia.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d308_f874_bc81_d93cde3107e9_MD0003_00 Peripartum cardiomyopathy (PPCM) is an uncommon cause of dilated cardiomyopathy that develops during the last month of pregnancy or within 5 months following delivery. This patient's clinical presentation with progressive dyspnea on exertion, lower extremity edema, and an S3 is suggestive of decompensated heart failure due to PPCM. PPCM often causes secondary mitral regurgitation, which can be recognized by a holosystolic murmur best heard at the apex. secondary mitral regurgitation The diagnosis of PPCM can be difficult in late pregnancy because many symptoms and signs (eg, dyspnea, edema) are similar to changes seen in normal pregnancy. This patient's S3, III/VI murmur, significant edema, and limiting dyspnea (needing to stop after walking a few steps) raise concern for PPCM. A transthoracic echocardiogram showing a dilated left ventricular cavity with global systolic dysfunction and ejection fraction <45% can confirm the diagnosis. Management is similar to that of other types of systolic heart failure (eg, beta blocker, diuretics). Urgent or immediate delivery should be considered only for patients with advanced heart failure or hemodynamic instability (Choice C). (Choice A) In patients with PPCM, chest x-ray typically reveals cardiomegaly, prominent pulmonary vascular congestion, and sometimes pleural effusions. However, these findings may be seen to some extent in the late stages of a normal pregnancy due to volume overload and diaphragm elevation; therefore, chest x-ray is of limited assistance in evaluating for PPCM. chest x-ray (Choice D) Magnesium sulfate is often used for the prevention of seizures in patients with preeclampsia. However, this patient's blood pressure does not meet the diagnostic criteria for preeclampsia (ie, >140/90 mm Hg). Magnesium sulfate is not used in management of PPCM. (Choice E) This patient may have PPCM and if so would be at high risk for fetal and maternal complications. Therefore, reassurance and routine care are not appropriate. Educational objective: Peripartum cardiomyopathy (PPCM) is an uncommon cause of dilated cardiomyopathy characterized by the development of heart failure during the last month of pregnancy or within 5 months following delivery. Patients with suspected PPCM should be evaluated using echocardiography. References: Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. (http://www.ncbi.nlm.nih.gov/pubmed/20675664) Peripartum cardiomyopathy: current state of knowledge, new developments and future directions. (http://www.ncbi.nlm.nih.gov/pubmed/24646160)

A 34-Year-Old Woman, Gravida 1 Para 0, Comes to the Office