<div>Heart Failure due to Peripartum
Cardiomyopathy Presenting in the First Week of Puerperium - A Case
Series from Nepal</div><div>Abstract: Peripartum cardiomyopathy (PPCM) is a rare cause of heart
failure associated with pregnancy without any other known cause. Most of
the clinical presentation is similar to symptoms of advanced pregnancy
making the diagnosis difficult. Reported are three patients who
developed dyspnea, orthopnea, and dry cough during the first week of
puerperium. On examination, bilateral lower limb edema and bilateral
basal lung crepitation were present in all patients. Chest radiograph
showed pulmonary edema in cases two and three, and pleural effusion in
case one. All patients had reduced left ventricular ejection fraction
and raised N-terminal pro-b-type natriuretic peptide (NT-proBNP) levels.
Case two developed PPCM in the background of left pyelonephritis. Case
three was complicated by acute kidney injury. All patients were managed
with bromocriptine, diuretics, beta-blockers, ACE inhibitors, and fluid
restriction. Hence, PPCM though rare should be considered as a
differential in women presenting with features of heart failure in later
months of pregnancy or within five months of delivery.</div><div>Keywords: heart failure, bromocriptine, peripartum dilated
cardiomyopathy, pregnancy, peripartum cardiomyopathy.</div><div>Introduction-</div><div>Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure
affecting women in the later months of pregnancy or within five months
of delivery. PPCM often presents when peak volume load, reached just
before delivery is greatly reduced after delivery.<sup>1,2</sup>PPCM affects women from all ethnicities globally with wide variation in
incidence from 1:20,000 live births in Japan to 1:100 in Zaria,
Nigeria.<sup>3,4</sup> With a prognosis that can vary from the
complete recovery of left ventricular function to maternal mortality as
well as recurrence with subsequent pregnancies, the study of PPCM has
been done sparsely in Nepal.<sup>2,5</sup> This case series
attempts to increase awareness of disease, diagnosis, and treatment in
Nepal.</div><div>CASE PRESENTATION</div><div>Case 1</div><div>A 33-years lady, G<sub>2</sub>A<sub>1</sub> at 38+6 weeks of
gestation, with no significant medical history underwent emergency LSCS
for non-progression of labor secondary to arrest of descent. On the
4<sup>th</sup> day of puerperium, she developed dyspnea on
exertion, orthopnea, bilateral lower limb edema, and dry cough. On
examination, she had increased blood pressure (160/110 mmHg) and
bilateral lower limb pitting edema with bilateral basal crepitation on
chest auscultation. Chest radiograph showed bilateral minimal pleural
effusion. Transthoracic echocardiography (TTE) showed severe left
ventricular systolic dysfunction, dilated left atrium (LA), moderate to
severe mitral regurgitation (MR), severe tricuspid regurgitation (TR),
moderate pulmonary artery hypertension (PAH) and reduced ejection
fraction i.e&lt; 25%. ECG showed T wave inversion in leads V1-V4
and aVL (figure 1). Serum N-terminal pro-b-type natriuretic peptide
(NT-proBNP) was 10897 pg/ml (Normal &lt;300). With the diagnosis
of PPCM, she was managed with fluid restriction, diuretics, beta
blockers, angiotensin receptor blockers (ARB), bromocriptine, and
antibiotics. Repeat TTE done on the 12<sup>th</sup> day of
puerperium showed EF of 30%. However, she had 3 episodes of syncopal
attack on the 19<sup>th</sup> puerperal day which was probably
due to orthostatic hypotension. She was discharged on the
22<sup>nd</sup> puerperal day with oral ARB and bromocriptine and
with close follow-up with cardiology and obstetrics and gynecology
clinic.</div>