April Mock Online Case: Heartfelt Pregnancy

It's finally spring and despite the Twin's opener and the gorgeous weather, you've hauled yourself into work to save some lives. 

A 43 year old Caucasian female presents to United ED triage complaining of anxiety and hallucinations. She is POD 5 from a scheduled repeat C-section and tubal ligation and was discharged home yesterday. She had no significant complications during this pregnancy and had no complications following her previous two deliveries. While in the hospital after delivery she started developing hallucinations that she described as hearing people talk to her.  Psychiatry was consulted and diagnosed her as "mild delirium of mixed origin, secondary to anesthesia, opioids and sleep deprivation."

She returns to the ED today accompanied by her husband and is roomed in the mental health suite.  She reports worsening hallucinations that are now described as hearing friends or nurses enter her room and ask if she's seen or read certain books or movies. Her husband states he doesn't think she has slept at all since coming home. She has a long standing history of insomnia (and does have a newborn at home) but on further questioning, this is different as she feels she can't lay down as she gets extremely short of breath laying flat.  She denies any new leg swelling, no dyspnea on exertion or feeling short of breath otherwise.

First Vitals:
    BP: 171/101 mmHg   Pulse: 87   Resp: 18    SpO2: 96 %          

Physical Exam with pertinent findings.  
Constitutional: She is oriented to person, place, and time and well-developed, well-nourished, and in no distress. 
HENT:  
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.  
Pulmonary/Chest: Effort normal. Crackles at both lung bases. 
Abdominal: Soft. There is no tenderness. There is no rebound and no guarding. C-section incision well healing. No signs of infection. 
Musculoskeletal: Trace edema bilateral lower extremities.  L>R  
Neurological: She is alert and oriented to person, place, and time. GCS score is 15. 
Skin: Skin is warm and dry. 
Psychiatric: Affect normal.  Speech is clear and fluent but repetitive.  Auditory hallucinations.

What would you do next?

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Labs:

Na 141

K 3.3

Cl 111

CO2 19

BUN 9
Cr 0.60

AST 24

ALT 19

Bili total 0.3

AP 104

Trop 0.020

BNP 365

CXR

Bilateral pulmonary infiltrates right > left due to pulmonary edema

ECHO

Normal LV size.

EF 40-45% with mildly reduced global left ventricular systolic function

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Patient was transferred to a regular ED room and noted to be severely dyspneic walking the 50 feet between rooms. Lasix 40mg IV and nitro paste 1" administered.  BP improved with these treatments.  Patient noted symptomatic relief while still in the ED.  

She was admitted to the United Hospitalist service with OB and cardiology consulting.  She was managed with lopressor, lisinopril, hydralazine and lasix.  Her weight dropped form 86kg to 78kg over the next two days, and she was discharged on hospital day #3.  Patient was able to sleep while admitted and she had no ongoing hallucinations.  Follow up with cardiology demonstrated complete resolution of her post-partum cardiomyopathy with no residual symptoms.  

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Questions:

1.  What is the time period a patient can develop peripartum or post partum cardiomyopathy?

          a. 1 month prior to delivery to 5 months post partum

          b. up to 9 months post partum

          c. any time post partum

          d. 2nd trimester onwards to 1 year post partum

2. What are the risk factors for developing peripartum cardiomyopathy? (choose any/all correct answers)

          - Maternal age >30

          - Multiparity

          - African descent

          - Multiple gestation

          - History of pre-eclampsia, eclampsia or post-partum hypertension

          - Maternal cocaine use

          - Long term oral tocolytic use

3.  True or False? ACE/ARBs are contraindicated for treatment of peripartum cardiomyopathy.

4.  What percentage of women have return to normal LV function?

          a. 95%

          b. none

          c. 20%

          d. 54%

5. True or False? Women with peri/post partum cardiomyopathy cannot reasonably consider a repeat pregnancy after returning to baseline LV function.

Answers:

1. a

2. all of the answers are correct

3. True

4. d, and almost all that recovered to baseline did so within the first 6 months.

5. False