1. By Dr/Ramy Ahmed Mahrose Assistant lecturer of Anesthesia, Intensive Care and Pain Management Faculty of Medicine Ain Shams University

2. History takings personal data 26 years old, Female patient, gravida 2 Para 1 (37 weeks gestation). Past history Irrelevant. family history Irrelevant.

3. At the ICU: The patient presented by dyspnea and tachypnea, She is orthopnic. No paroxysmal nocturnal dyspnea. There is no chest pain. No cough. No hemoptysis.

4. By history these symptoms have developed acutely and progressively in the previous 2 days. Her last pregnancy passed uneventful and delivered a healthy baby at 40 weeks by normal vaginal delivery.

6. Chest examination: Chest examination: - There was bilateral fine basal crepitation. Cardiac examination : - Revealed pan systolic murmur heard at the - Revealed pan systolic murmur heard at the apex of the heart. apex of the heart. Abdominal examination: -The abdominal examination was -The abdominal examination was unremarkable, the liver and spleen are not unremarkable, the liver and spleen are not enlarged. enlarged.

7. Investigations: *Laboratory investigations: *Laboratory investigations: - CBC: HB 11gm%, Plt 300,000/ microliter, - CBC: HB 11gm%, Plt 300,000/ microliter, WBCs 15000/ microliter. WBCs 15000/ microliter. - Coagulation profile: INR 1.1,PTT 30 seconds. - Coagulation profile: INR 1.1,PTT 30 seconds. - Chemistry:BUN 20 mg /dl, s.creat. 0.9 mg/dl - Chemistry:BUN 20 mg /dl, s.creat. 0.9 mg/dl ALT 40 units/litre serum, AST 35 u/LS, s. albumin 2.5 gm./dl, K 3.9 meq/L, Na 143 meq/L, CK total 90 units/ liter, CK- ALT 40 units/litre serum, AST 35 u/LS, s. albumin 2.5 gm./dl, K 3.9 meq/L, Na 143 meq/L, CK total 90 units/ liter, CK- MB 20 units/liter, Troponin negative. MB 20 units/liter, Troponin negative.

8. -ABG: -ABG: on room air, revealed: on room air, revealed: PH:7.46 PH:7.46 PO 2 :62 mmhg. PO 2 :62 mmhg. PCO 2: 27 mmhg. PCO 2: 27 mmhg. HCO 3:18 mmole/L HCO 3:18 mmole/L O 2 Sat.:90% O 2 Sat.:90%

10. CXR: Shows cardiomegaly and some Shows cardiomegaly and some interstitial lung edema. interstitial lung edema.

11. Echocardiography(Bed side at ICU): - Ejection fraction 40%. –No diastolic dysfunction. -Global hypokinesia. -Severe mitral regurge. -Dilated left atrium and ventricle. -RVSP: 35 mmhg.

12. Differential diagnoses: Many presenting complaints observed in patients with cardiac disease occur during a normal pregnancy. Dyspnea, dizziness, orthopnea, and decreased exercise capacity often are normal symptoms in pregnant women. Mild dyspnea upon exertion is particularly common in a normal pregnancy.

13. The classic dyspnea of pregnancy is thought to be due to the progesterone-mediated hyperventilation. New or rapid onset of the symptoms requires prompt evaluation.

14. - - Peripartum cardiomyopathy(PPCM) in accompany with preeclampsia: As the patient presented at last month of pregnancy with impaired left ventricular systolic function and no history of underlying cardiac disease, preeclampsia may be a predisposing factor for PPCM.

15. -Preeclampsia complicated by pulmonary edema: Hypertension and increased afterload may lead to heart failure but this is associated with diastolic dysfunction and right ventricular failure more than left ventricular failure.

16. -Severe mitral regurge complicated by heart failure : But there is no history suggestive of preexisting cardiac valve disease and this valve affection may be a complication of cardiomyopathy and heart failure.

17. - - Idiopathic dilated cardiomyopathy: It has clinical characteristics similar to PPCM but the onset is not restricted to the peripartum period and can occur in the second trimester.

18. Management: -Monitoring of the patient using the standard monitor ( non invasive blood pressure measurement,pulse oximetry and ECG). -Establishing intravenous axis by inserting peripheral cannula and central venous line.

19. -Inserting urinary catheter to evaluate urine output. -Oxygen therapy : by oxygen mask 6L/min. - Drug therapy: #Diuresis was started with intravenous furosemide shots to decrease the preload and relieve the congestion. #Controlling of hypertension using intravenous nitroglycerin infusion (0.5-10 mic/kg/min) to decrease the afterload.

20. #Magnesium sulfate infusion (1 gm./hour for 24 hours) for prophylaxis against eclampsia. #Anticoagulant( Tinzaparin 0.45 ml/day) is important as there is a high risk of developing thromboembolic phenomena. #Pantoprazole (40 mg/24 hour)for prophylaxis against stress ulcer.

21. - Delivery of the baby: #By induction of normal vaginal delivery which is better than caesarian section as it is associated with less bleeding and avoids the risk of anesthesia.

22. The patient developed marked improvement of her condition, dyspnea improved, the respiratory rate returned to near normal range, orthopnea disappeared and chest became clear by auscultation, blood pressure became within normal range, oxygen saturation 95% on room air, pulse rate 90 bpm.

23. The patient discharged to ward after 3 days with the following recommendations: -Follow up patient vital data. -Echocardiography( 2 months after delivery) to follow up the cardiac condition. -A low-salt diet was recommended. -Activities, including nursing the baby, may be limited when symptoms develop.

24. -Treatment: #Diuretics(Furosemide 40 mg tab/24 #Diuretics(Furosemide 40 mg tab/24 hr.). hr.). #ACEI(Captopril 25 mg tab/8hr) to #ACEI(Captopril 25 mg tab/8hr) to control HTN and decrease afterload. control HTN and decrease afterload. # Beta blocker (Carvidolol 6.25 mg twice # Beta blocker (Carvidolol 6.25 mg twice /day) it has vasodilator effect without /day) it has vasodilator effect without tachycardia also it improve systolic tachycardia also it improve systolic function and it improves the survival function and it improves the survival of patients. of patients.