Concurrent early-onset peripartum cardiomyopathy in a preeclampsia patient with acute pulmonary edema

Clinical Characteristics of Postpartum Women With Hypoxia: A Retrospective Analysis of 92 Cases

Purpose

Postpartum hypoxia is a significant concern among clinicians due to its association with fatal diseases such as amniotic fluid embolism. This study analyzed the clinical characteristics of patients with different etiologies of postpartum hypoxia.

Patients and Methods

Ninety-two postpartum cases with hypoxia, defined as oxygen saturation (SpO2) < 95% within 48 h postpartum without supplemental oxygen inhalation, and 100 normal gravidas were enrolled. All patients with postpartum hypoxia underwent 24 h vital sign monitoring and relevant examinations, including hematological tests, chest computed tomography (CT) scans, or CT pulmonary angiography, to determine the cause of hypoxia and received appropriate treatments. All patients were followed up for 1 month.

Results

Compared with normal gravidas, the patients with postpartum hypoxia had a higher occurrence rate of complications, including gestational hypertension (26.09% vs 8.00%), eclampsia (20.65% vs 4.00%), and a lower level of albumin (29.09 ± 0.57 vs 32.74 ± 0.94), thus tended to have longer hospitalization days (7.98 ± 0.40 vs 4.90 ± 0.16), with all P < 0.05. In all 92 cases, the most common cause of postpartum hypoxia was partial atelectasis with pleural effusion (65/92), followed by pulmonary edema (18/92), pneumonia (9/92), pulmonary embolism (6/92), and asthma (4/92). Among the five groups, patients with pneumonia had the longest hospital stay, whereas most patients with partial atelectasis accompanied by pleural effusion were asymptomatic. From the 1-month follow-up, all patients had a favorable prognosis with no apparent symptoms. Among those who underwent re-examination (27/92), no apparent imaging abnormalities were detected.

Conclusion

Postpartum hypoxia, which occurs more commonly in patients with gestational hypertension, is often caused by partial atelectasis with pleural effusion or pulmonary edema. The patient's prognosis was generally satisfactory after treatment.

Do Case Reports and Case Series Generate Clinical Discoveries About Preeclampsia? A Systematic Review

Background

Preeclampsia is a leading cause of maternal and perinatal mortality and morbidity. The management of preeclampsia has not changed much in more than two decades, and its aetiology is still not fully understood. Case reports and case series have traditionally been used to communicate new knowledge about existing conditions. Whether this is true for preeclampsia is not known.

Objective

To determine whether recent case reports or case series have generated new knowledge and clinical discoveries about preeclampsia.

Methods

A detailed search strategy was developed in consultation with a medical librarian. Two bibliographic databases were searched through Ovid: Embase and MEDLINE. We selected case reports or case series published between 2015 and 2020, comprising pregnant persons diagnosed with hypertensive disorders of pregnancy, including preeclampsia. Two reviewers independently screened all publications. One reviewer extracted data from included studies, while another conducted a quality check of extracted data. We developed a codebook to guide our data extraction and outcomes assessment. The quality of each report was determined based on Joanna Briggs Institute (JBI) critical appraisal checklist for case reports and case series.

Results

We included 104 case reports and three case series, together comprising 118 pregnancies. A severe presentation or complication of preeclampsia was reported in 81% of pregnancies, and 84% had a positive maternal outcome, free of death or persistent complications. Only 8% of the case reports were deemed to be of high quality, and 53.8% of moderate quality; none of the case series were of high quality. A total of 26 of the 107 publications (24.3%) included a novel clinical discovery as a central theme.

Conclusion

Over two-thirds of recent case reports and case series about preeclampsia do not appear to present new knowledge or discoveries about preeclampsia, and most are of low quality.

Middle range theory for the nursing diagnosis Excess Fluid Volume in pregnant women

OBJECTIVE

To stablish a middle range theory for the understanding of the causal mechanisms and clinical consequentes of the nursing diagnosis Excess Fluid Volume (00026) among pregnant women.

METHOD

The Middle Range Theory was constructed in five stages: defining of construction approach, establishing main concepts, elaborating propositions, developing a pictorial diagram, and establishing the causal relationships and evidence for practice of the Middle Range Theory.

RESULTS

We identified 14 clinical indicators and 6 causal factors of Excess Fluid Volume. A pictorial diagram was developed and relationships between Excess Fluid Volume elements were established with 6 propositions for them.

CONCLUSION

The Middle Range Theory included both physiological and pathological conditions to explain Excess Fluid Volume. This Middle Range Theory might help in the better understanding of interactions between causal factors and clinical indicators of Excess Fluid Volume.

Peripartum Cardiomyopathy: Current Options for Treatment and Cardiovascular Support

Peripartum cardiomyopathy is a rare form of acute heart failure but the major cause of all deaths in pregnant patients with heart failure. Improved survival rates in recent years, however, emphasize the importance of early recognition and initiation of heart failure treatment. This article, therefore, attempts to raise awareness among cardiac and obstetric anesthesiologists as well as intensivists of this often fatal diagnosis. This review summarizes theories of the pathophysiology and outcome of peripartum cardiomyopathy. Based on the most recent literature, it further outlines diagnostic criteria and treatment options including medical management, mechanical circulatory support devices, and heart transplantation. Earlier recognition of this rare condition and a new generation of mechanical circulatory devices has contributed to the improved outcome. More frequently, patients in cardiogenic shock who fail medical management are successfully bridged to recovery on extracorporeal circulatory devices or survive with a long-lasting implantable ventricular assist device. The outcome of transplanted patients with peripartum cardiomyopathy, however, is worse compared to other recipients of heart transplants and warrants further investigation in the future.

Reversion of Severe Mitral Insufficiency in Peripartum Cardiomyopathy Using Levosimendan

Idiopathic peripartum cardiomyopathy presenting with heart failure is a true diagnostic and treatment challenge. Goal oriented clinical management aims at the relapse of left ventricular systolic dysfunction. A 35-year-old patient on her 12th day post-delivery presents progressive signs of heart failure. Transthoracic echocardiography showed severe mitral insufficiency, mild left ventricular dysfunction, mild tricuspid insufficiency, severe pulmonary hypertension, and right atrial enlargement. With wet and cold heart failure signs, the patient was a candidate for inodilator cardiovascular support and volume depletion therapy. As the patient presented a persistent tachycardia at rest, levosimendan was chosen over dobutamine. Levosimendan was administered at a dose of 0.2 µg/kg/min during a period of 24 hours. After inodilator therapy, the patient's signs and symptoms of heart failure began to decrease, showing improvement of dyspnea, mitral murmur grade went from IV/IV to II/IV, filling pressures and systemic and pulmonary resistance indexes decreased, arterial blood gases improved, and an echocardiography performed 72 h later showed non-dilated cardiomyopathy, mild cardiac contractile dysfunction, mild mitral insufficiency, type I diastolic dysfunction and improvement of pulmonary hypertension. Cardiovascular function in peripartum cardiomyopathy tends to go back to normality in 23-41% of the cases, but in a large group of patients, severe ventricle dysfunction remains months after initial symptoms. This article describes the diagnostic process of a patient with peripartum cardiomyopathy and a successful reversion of a severe case of mitral insufficiency using levosimendan as a new therapeutic strategy in this clinical context.