title: Peripartum cardiomyopathy: postpartum decompensation and use of non-invasive cardiac output monitoring.
abstract: The utility of a non-invasive cardiac output monitor (NICOM™) in guiding the peripartum management and identification of postpartum complications in a patient with severe peripartum cardiomyopathy is reported. A 31-year-old nulliparous woman at 35 weeks of gestation presented with a three-week history of worsening dyspnea and progressive functional deterioration. A transthoracic echocardiogram showed severe left ventricular systolic dysfunction with an ejection fraction <20%. Cardiac status was monitored using NICOM™ during labor and delivery. The baseline values were: cardiac output 5.3 L/min, total peripheral resistance 1549 dynes.sec/cm(5), stroke volume 42.1 mL and stroke volume variation 18%. She received early epidural analgesia during labor, titrated slowly with a loading dose of 0.0625% bupivacaine 10 mL and fentanyl 25 μg, followed by patient-controlled epidural analgesia (0.0625% bupivacaine with fentanyl 2 μg/mL, infusion at 10 mL/h, bolus dose 5 mL and lockout interval 10 min). After epidural drug administration, total peripheral resistance decreased, cardiac output increased, and satisfactory analgesia was obtained. She had an uneventful vaginal delivery with a forceps-assisted second stage after prophylactic administration of furosemide 20 mg. NICOM™ was discontinued after delivery. Fifteen hours post-delivery, the patient developed cardiogenic shock, which resolved after aggressive therapy with inotropes and furosemide. NICOM™ can be used to guide treatment during labor and delivery in patients with critical peripartum cardiomyopathy. We suggest that use of NICOM™ be extended into the postpartum period to detect signs of cardiac decompensation in such patients.
authors.affiliation: Department of Anesthesia and Pain Management, Mount Sinai Hospital, Toronto, ON, Canada.
authors.forename: G
authors.initials: G
authors.lastname: Lorello
authors.affiliation: Department of Anesthesia and Pain Management, Mount Sinai Hospital, Toronto, ON, Canada.
authors.forename: J
authors.initials: J
authors.lastname: Cubillos
authors.affiliation: Department of Cardiology, Mount Sinai Hospital, Toronto, ON, Canada.
authors.forename: M
authors.initials: M
authors.lastname: McDonald
authors.affiliation: Department of Anesthesia and Pain Management, Mount Sinai Hospital, Toronto, ON, Canada. Electronic address: mrinalini.balki@uhn.ca.
authors.forename: M
authors.initials: M
authors.lastname: Balki
mesh_terms: D000328:Adult; D002302:Cardiac Output; D002311:Cardiomyopathy, Dilated / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D002316:Cardiotonic Agents / Q000627:therapeutic use; D036861:Delivery, Obstetric; D004232:Diuretics / Q000627:therapeutic use; D005260:Female; D005665:Furosemide / Q000627:therapeutic use; D006801:Humans; D008991:Monitoring, Physiologic / Q000379:methods*; D058725:Peripartum Period; D049590:Postpartum Period; D011247:Pregnancy; D012770:Shock, Cardiogenic / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy
chemical_list: D002316:Cardiotonic Agents; D004232:Diuretics; D005665:Furosemide
keywords: Cardiogenic shock; NICOM™; Peripartum cardiomyopathy