A case of postpartum pulmonary edema with preserved ejection fraction and diastolic capacity

A case of postpartum pulmonary edema with preserved ejection fraction and diastolic capacity

Perinatal cardiomyopathy is a rare condition in which a healthy woman develops left ventricular dysfunction and heart failure during the perinatal period. [1]. Diagnostic criteria for perinatal cardiomyopathy include a decreased ejection fraction (EF) of less than 45% on echocardiography. [2]. Recently, however, cases of peripartum cardiomyopathy have been reported in which ejection fraction is preserved but left ventricular diastolic dysfunction develops, resulting in heart failure. [3]. In this report, we describe a case of postpartum heart failure with normal EF and no left ventricular diastolic dysfunction, but with transient left ventricular enlargement and mitral regurgitation (MI).

A 21-year-old female patient with G1P0 conceived spontaneously and underwent prenatal care in our hospital. She had no prior medical history or history of heart disease. The pregnancy was uneventful. A blood test at 36 weeks and five days’ gestation revealed a hemoglobin (Hb) of 9.9 g/dl. She gave birth spontaneously via vaginal delivery at 40 weeks and 0 days. During delivery, a laceration to the posterior vaginal vault occurred, resulting in a blood loss of 1577 g. Blood was drawn and the Hb level dropped to 5.3 g/dl. Red blood cells (RBC) 4U were transfused and the Hb level improved to 7.1 g/dl. She was discharged to her home on the sixth postpartum day. On the morning of the eighth day postpartum, she developed respiratory distress. As her symptoms did not improve, she went to the emergency department of our hospital. At the time of the visit, his vital signs were Blood Pressure (BP) 134/85 mmHg, Heart Rate (HR) 105 bpm, Peripheral Artery Oxygen Saturation (SpO2) 95% (room air) and Body Temperature (BT) 37 .1℃ Auscultation revealed fine bilateral cracking on both sides. Hb was 7.3 g/dl. The results of the blood test after a visit to our clinic are shown in Table 1.

day 0 Day 1 Day 2 Day 4
WBC (/μl) 122 119.9 116.7 90.9
Hb (g/dl) 7.3 7.9 9 8.6
plt (/μl) 35.6 38.1 41.3 51.7
Alba (g/dl) 2.77 2.63 2.92 2.92
AST (U/L) twenty-one twenty 18 fifteen
ALTERNATIVE (U/L) twenty-one 31 32 22
DL (U/L) 3. 4. 5 342 427 285
BUN (mg/dl) 8 7 9 eleven
Cr (mg/dl) 0.76 0.59 0.52 0.47
Na (mEq/l) 144 141 143 142
K (mEq/l) 3.6 3.8 4.2 4.2
Cl (mEq/l) 114 105 108 111
CRP (ng/mL) 1.07 6.75 5.25 1.47

Computed tomography (CT) of the chest showed increased vascular shadows and pleural effusion in bilateral lung fields (Figure 1) and frosty shadows in the upper lung fields (Figure two). Suspecting pneumonia, treatment with ceftriaxone was started. As the patient had not been vaccinated against coronavirus disease 2019 (COVID-19), the possibility of COVID-19 pneumonia was also considered, so the patient was admitted to the isolation room after undergoing a blood test. polymerase chain reaction (PCR). Since more than 6 hours had passed since the transfusion, TACO (Transfusion-associated circulatory overload) was considered negative. Four hours after admission, oxygenation worsened to the point that the patient required 5L of oxygen through a mask. The patient was transferred to a higher facility where he was available for intensive care. The PCR performed at the new hospital was negative. A second PCR test administered at the hospital also returned negative results, ruling out a diagnosis of COVID-19 pneumonia.

The patient was transported back to our hospital after oxygenation improved with oxygen administration alone, and the oxygen volume was reduced to 2 L via nasal cannula. Echocardiogram performed at the higher institution showed EF 55%~60%, preserved cardiac output, and negative troponin. The echocardiogram performed in our hospital showed a slightly enlarged left ventricular dimension (LVD) of 53 mm (normal value: 39-55 mm) and mild MI. Early diastolic mitral annular velocity (E`) was 8.8 cm/s, ratio of early transmitral flow velocity to early mitral annular velocity (E/E`) was 12.1, volume index of the left atrium (LA) was 28.2 ml/mtwo, and tricuspid regurgitation (TR) was trivial, but peak TR velocity was 2.8 m/s, and heart failure with preserved ejection fraction (HFpEF) was 55% to 60%. The diagnostic criteria for HFpEF were not met. Echocardiography showed preserved EF and no impairment of diastolic function, but the presence of pulmonary edema, leg edema, and an elevated brain natriuretic peptide (BNP) level of 170.6 pg/mL led to a diagnosis of heart failure. Continuous administration of furosemide 20 mg/day and 1 L of oxygen was started as treatment for heart failure.

Oxygenation gradually improved, and oxygen administration was completed on the fourth hospital day. The patient was discharged home on the fifth day of hospitalization. Hb was 8.6 g/dl. Chest radiographs were normalized at discharge (Fig. 3). Echocardiography performed three months after delivery showed that the LVD had reduced to 50 mm and the MRI normalized.

In this case, the ejection fraction was preserved on echocardiography and there was no evidence of diastolic dysfunction, but the diagnosis of heart failure was made based on decreased oxygenation, computed tomography findings of the lungs, and BNP. greater than 150 pg/ml. [4].

HFpEF is diagnosed when the patient develops clinical symptoms of heart failure and when echocardiography shows preserved EF but impaired diastolic function. [5]. Peripartum cardiomyopathy is usually diagnosed when the EF falls below 45%. [2], but in this case the EF was preserved, so the possibility of HFpEF was considered. However, since diastolic function was normal, HFpEF was not diagnosed. It has been reported that perinatal heart failure patients with preserved EF do not develop left ventricular enlargement. [6]. Our case, in which left ventricular enlargement with preserved EF and no diastolic dysfunction occurred, is different from previous cases of perinatal heart failure.

The development of heart failure, in this case, may be related to the fact that the patient was anemic. Anemia has been reported to be a prognostic factor for heart failure. [7]. Also, having an Hb level of less than 6 g/dl during pregnancy is associated with poor pregnancy outcomes. [8]. In the present case, the patient’s Hb decreased to 5.3 g/dl due to abundant bleeding during delivery, and a 4U RBC transfusion was performed, which improved Hb to 7.1 g/dl but did not normalize the situation. . Therefore, anemia and perinatal heart failure may be related. However, we do not know if the anemia caused or exacerbated the perinatal heart failure in this case. Therefore, future studies examining the association between anemia and postpartum heart failure are warranted.

We experienced a case of postpartum heart failure with normal EF and diastolic function on echocardiography, but with temporary left ventricular enlargement and MRI. Since anemia is suspected to be associated with this case, future studies on anemia in postpartum heart failure are warranted.

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