This is an interesting case of
Dilated Cardiomyopathy with LVEF of 30%, diagnosed as Post Partum Cardiomyopathy, of 24 years aged female.
Her complaints started in 2006, after the delivery. Two months after delivery, she started with complaints of loose motions, loss of appetite, increased thirst and decreased urinary output. She also experienced pain in abdomen and backache.
It was suspected to be some kind of cardiac complaints by her local physician; but patient neglected it and didn’t take any treatment for the same.
Shortly her complaints worsened and she experienced severe breathlessness, chest pain and oedema all over the body. As her condition was critical she was kept in I.C.U. Subsequently with proper investigations she was diagnosed to be having dilated Cardiomyopathy, Post Partum Cardiomyopathy. Along with that her reports of
Ultrasonography showed Ascitis with Bilateral Pleural Effusion.Later on she continued Allopathic treatment, but missing a single medicine at times would aggravate her complaints.
She was restricted for ascending stairs and lifting weight. She couldn’t perform her daily activities as she frequently had attacks of breathlessness.
Due to her prolong sufferings, she was much frustrated.
Peripartum / Postpartum cardiomyopathy:
Peripartum cardiomyopathy (PPCM): is a form of dilated cardiomyopathy that is defined as deterioration in cardiac function presenting typically between the last month of pregnancy and up to five months postpartum. As with other forms of dilated cardiomyopathy, PPCM involves systolic dysfunction of the heart with a decrease of the left ventricular ejection fraction (EF).
Causes:
Viruses, autoimmunity or immune system dysfunction, other toxins that serve as triggers to immune system dysfunction, micronutrient or trace mineral definciencies, and genetics as possible components that contributes to or causes the development of PPCM.
Cardiomyopathy occurs when there is damage to the heart. As a result, the heart muscle becomes weak and cannot pump blood efficiently. Decreased heart function affects the lungs, liver, and other body systems.
Peripartum cardiomyopathy is a form of dilated cardiomyopathy in which no other cause of heart dysfunction (weakened heart) can be identified.
Risk factors include obesity, having a personal history of cardiac disorders such as myocarditis, use of certain medications, smoking, alcoholism, multiple pregnancies, and being malnourished.
Symptoms
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Fatique
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Feeling of racing heart or skipping beat (palpitations) and chest pain.
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Increased night-time urination (nocturia)
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Orthopnea (difficulty breathing while lying flat), dyspnea (shortness of breath on exertion).
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Pitting edema (swelling)
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Cough
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Excessive weight gain during the last month of pregnancy (1-2+ kg/week; two to four or more pounds per week).
The shortness of breath is often described by PPCM patients as the inability to take a deep or full breath or to get enough air into the lungs. Also, patients often describe the need to prop themselves up overnight by using two or more pillows in order to breathe better. These symptoms, swelling, and/or cough may be indications of pulmonary edema (fluid in the lungs) resulting from acute heart failure and PPCM.
Prognosis:
There are several possible outcomes in peripartum cardiomyopathy. Some women remain stable for long periods, while others get worse slowly.
Others get worse very quickly and may be candidates for a heart transplant. The death rate may be as high as 25 - 50%.
The outlook is good for women whose hearts returns to normal size after the baby is born. If the heart remains enlarged, future pregnancies may result in heart failure. It is not known how to predict who will recover and who will develop severe heart failure.
Women who develop peripartum cardiomyopathy are at high risk of developing the same problem with future pregnancies.
Possible Complications
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Cardiac arrhythmias (can be deadly)
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Congestive heart failure
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Pulmonary emboli.
Investigations:
14.07.2006 : Color Doppler :
- Dilated LA & LV cavity.
- Global Hypokinesia of LV.
- Poor EF 30%
- Impression : Post Partum Cardiomyopathy.
14.07.2006 :USG Abdomen & Pelvis :
- Minimal free fluid noted in the pelvis.
- Moderate amount of fluid in both CP angles with underlying consolidation of Rt. Side.
- Impression: B/L Pleural effusion with underlying consolidation on Rt. Side.
- Ascites.
12.10.2006: ECG:Sinus rhythm, Second degree AV block, possible abnormal ECG.
21.07.2006 : Sr. Bilirubin : 2.4, S.G.P.T. : 51
Her complaints in detail were as follows :
C/C:
1. Breathlessness with chest pain since 3 yrs.
- Complaints started 3 months after delivery. (H/O FTND).
- It started with continuous diarrhea for 4 days, loss of appetite, decreased urine output, breathlessness along
with pain in ribs & back.
- Since then c/o breathlessness off & on.< Walking fast.
< Exertion. > Fanning.
< Mental stress. > Sitting with support.
< Cold, coryza during.
< Summer.
- Chest pain off & on.
Onset : Gradual. Decline : Gradual.
Location : Pain at Lt. side of chest – Rt. Side.
Also c/o pain along ribs extending backward to scapular region.
Lt. – Rt., Lt. > Rt.
< Mental Stress. > Sitting with support.
< Walking. > Lying down.
< Exertion. > Sleep after.
< Weight lifting.
< Loss of sleep
2. Pain in legs ∵3 yrs, increased ∵2 yrs.
- Duration : Once started it persists for 2 days.
- Location : Pain radiating from thigh to ankle.
- Tingling & Numbness of both legs occasionally.
- Lt. > Rt.
< Walking.
< Summer. > Rest.
> Rubbing.
3. Headache off & on ∵ 4 yrs.
- Duration : Continuous for 2 days.
- Location : Forehead along eyebrows & lat. side of head extending to lat. side of nape of neck, occiput & extends
to shoulder. Lt. – Rt.
- Sometimes pain only in the half side either Lt./Rt.
- Character : Throbbing pain.
< Empty stomach. > Watering from eyes.
< Sun exposure. > Rest.
< Afternoon. > Sleep after.
Concomitant :
- Watering of eyes; sometimes burning.
- Earache. Lt. – Rt. Lt. > Rt.
Past History :
- H/O head injury by fall of wood on head.
Family History:
- Mother : Migraine.
Personal History:
- Diet : Mixed.
- Appetite : Good. Can’t tolerate hunger.
- Desire : Pungent/ Sweets / Milk / Ice-cream.
- Food< : Sweets < Headache.
- Eyes : Spects for near vision.
- Ears : Earache during headache.
Lt. – Rt. Lt. > Rt.
- Nose :Repeated attacks of cold & coryza.
< Cold air draft
< Wetting in rain.
- Tongue : Pale, moist.
- Thirst : Thirsty. S.Q.S.I.
- Abdomen : Pain in abdomen off & on since 4 yrs.
Location : Lt. lumbar region. Sometimes extends to Rt.
Lt. to Rt. But Lt. > Rt.
Sensation of bloatedness of abdomen with flatulence.
< Empty stomach
< Walking.
- Bowel : Satisfactory – Semisolid &yellow. Straining sometimes with hard stool.
- Bladder : Urine output is less if she misses diuretics.
- Perspiration: Moderate over face & neck.
- Sleep : Night : 11:00 am – 6:00 am. Afternoon : 1hour sleep. Unrefreshing sleep.
Startles in sleep sometimes.
A/F loss of sleep.
Sleeplessness in 1st part, thinking more at that time.
Position : Lies on sides.
Coverings up to head.
- Dreams : Fearful dreams.
- Thermal : CHILLY.
Mind:
1. Tell me about your childhood?
I belong to village background. I have completed my studies till 10th std. I was good in studies but couldn’t
complete or study further due to our poor financial condition and orthodox family.
We were 2 brothers and one sister. I was the younger most and hence a pampered child. I was short tempered & I
used to fight a lot with my brothers. Fights were common for me while playing with my friends.
2. Tell me about your nature?
By nature I am irritable. Anything done against my will shoots up my anger.
If anyone doesn’t listen to me for e.g. doesn’t get the said things from the market, I get annoyed & anger remains
in mind for long. I like cleanliness & things to be organized. If they are not…it also irritates me.
Loves solitude but cannot stay alone at night because of fear of dark. I don’t like to mix up much.
Usually, I don’t weep easily.
I have good relations with my husband.
3. About your worries & tensions?
I got married in 2003. We lived as a separate family. Our financial condition was bad. Husband was working but his
salary was less; hence faced many financial problems.
After delivery baby was not feeding well and cried continuously day & night. It was difficult to manage as I would
become very irritable for every small thing. That situation was very stressful for me.
I am tensed about my son’s future as I can’t look after him due to my diseased state.
Totality:
- Irritable. Short tempered.
- Insecurity feeling.
- Contradiction intolerance of.
- Fastidious.
- Solitude desire.
- Sensitive to mortification.
- Fear of dark.
- Fearful dreams.
- Chilly.
- Radiating pain.
- Chronic coryza.
- Lt. – Rt. Complaints.
- A/F : Loss of sleep.
- Unrefreshing sleep
- Scanty urination.
- < Sweets.
- < Exertion.
- < Walking.
- < Sun.
- < Weight lifting.
- < Getting wet in rain.
- > Bending backward.
Response:
Medicine was started on 24.06.2009. She was admitted in my hospital for better observation.
Regular B.P., Pulse, Urine input / output and other parameters were closely monitored. They showed gradual
improvements. These were the objective parameters.
Breathlessness, chest pain, & headache showed improvement since time of admission.
Besides this, her follow-up 2D-echo reports also showed good improvement as follows.
23.07.2009:
- Mild Mitral Valve Prolapse.
- Normal PA pressure.
- Good Biventricular function with Ejection fraction of 55%.
29.04.2010:
- Normal chamber dimensions.
- Patent foramen ovale.
- Valves are structurally normal.
- EF : 55%
Now about 1½ year has passed and she has no complaint of breathlessness or chest pain & can ascend stairs
comfortably.
Patient is actively performing her daily routine work. She looks after her child properly.
Her headache and leg pain have stopped.
Patient has completely stopped the allopathic medicines.
The most important thing to mention is that Ejection fraction increased from 30% to 55% which is difficult to
be achieved by Modern medicine treatment.