40 year old woman

Question 1

What is the number cause of hyperthyroidism?

Answer 1

Grave’s Disease

Question 2

Grave’s disease gender

Answer 2

7-8 times more likely to affect women than men

Question 3

Age of diagnosis of grave’s disease

Answer 3

Peak age of diagnosis is between 40-60

Question 4

What are the causes of dyspnea and hypoxemia in the peripartum period?

Answer 4

Origins are predominantly pulmonary or cardiovascular

Question 5

Pulmonary causes of dyspnea and hypoxemia post partum

Answer 5

Common: Pulmonary embolism, pneumonia, aspiration pneumonitis, reactive airway disease
Rare: ARDS, Amniotic-fluid embolism, vasculitis, pulmonary hypertension, pneumothorax

Question 6

What causes pulmonary embolism in postportam?

Answer 6

Stasis, hypercoagulable blood, and vascular/endothelial damage (from vascular compression at delivery or from assisted or operative delivery)

Question 7

How much does pregnancy affect coagulation of blood?

Answer 7

• Pregnancy is a prothrombotic state with nearly 5x increased risk of VTE
• The peripartum period is a hypercoagulable state, most likely an evolutionary adaptation to minimize postpartum hemorrhaging
• Venous thromboembolism occurs in 1 or 2 in 1000 pregnancies and is
  approximately 10 times as likely post partum as during pregnancy

Question 8

Are tachycardia and bloody sputum diagnostic of pulmonary embolism in a post partum woman?

Answer 8

Tachycardia and bloody sputum are consistent with, but not diagnostic
of, pulmonary embolism

Question 9

Risk of pneumonia during and after pregnancy

Answer 9

• Pregnant women have immune tolerance , which is most likely an
  evolutionary adaptation to preclude maternal rejection of the fetus
• Immune tolerance , anatomical changes during pregnancy , and the risk
  of aspiration during cesarean delivery increase risk for pneumonia .

Question 10

Effect of pregnancy on rheumatological diseases

Answer 10

• Improvement in 50-75% of RA patients
• Flare in 50% of SLE patients
• Aggravation of APS

Question 11

Risk of maternal complication in pregnancy in women with rheumatological diseases

Answer 11

• No risk for RA
• Hematological and renal complication are the most frequent in SLE
• Thrombosis in APS patients

Question 12

Risk for pregnancy complications in rheumatological diseases

Answer 12

• Moderate increase in RA
• Hypertension, pre-eclampsia, and prematurity for SLE
• Preeclampsia, prematurity, HELLP syndrome in APS

Question 13

Risk for fetus/neonate in rheumatological diseases

Answer 13

• Very rare for RA
• Fetal loss, intrauterine growth restriction, low birthweight, and neonatal lupus in SLE
• Fetal loss, intrauterine growth restriction, low birthweight in APS

Question 14

Vasculitis in pregnancy and in this particular patient

Answer 14

• The immune tolerant state of pregnancy can also provide a “ holiday ” from vasculitides , which can rebound post partum
• In this patient, the absence of inflammatory signs and negative tests for ANA and dsDNA make a diagnosis of vasculitis unlikely
• Results of tests for antineutrophil cytoplasmic antibodies and human
  immunodeficiency virus would be helpful

Question 15

Embolism in this particular patient

Answer 15

CT finding renders a large pulmonary embolism highly unlikely. Emboli
in the small branches of the pulmonary arteries cannot be ruled out, but
is unlikely that these would be manifested as hemodynamic collapse

Question 16

Pneumonia in this particular patient

Answer 16

Absence of fever and of an elevated leukocyte count , in concert with findings on chest radiography and CT, makes infection unlikely

Question 17

What is the cause and clinical feature of amniotic fluid embolism

Answer 17

• Amniotic fluid containing fetal cells, hair, and fetal debris, as well as procoagulant and fibrinolytic activators from injured blood vessels, are released into maternal circulation during labor due to disruption of maternal fetal interface
• If they lodge in the lung it can lead to pulmonary collapse and eventually ARDS
• It may also create a anphylactoid reaction which would lead to vascular collapse
• It may also cause extrinsic coagulation and fibrinolysis pathway activation, leading to DIC and prolonged postpartum bleeding
• Symptoms include sudden onset of dyspnea and shock during labor, pulse oximetry may show sudden drop in O2 saturation, hypotension
• cyanosis, confusion, irritability or seizures may be presenting signs
• Blood studies may show decreased fibrinogen and elevated fibrin split products, thrombocytopenia, and prolonged PT and PTT, all suggestive of DIC

Question 18

What are risks in this patient that can open the door for the development of amniotic fluid embolism, and what makes us think otherwise?

Answer 18

• Advanced maternal age and delivery by C section place Mariah at risk
  for amniotic fluid embolism
• This is a rare but catastrophic complication of pregnancy or labor
• Patients with amniotic fluid embolism usually present with cardiorespiratory collapse , which Mariah had ; this is typically accompanied by disseminated intravascular coagulation and systemic
  inflammatory responses , which Mariah did not have
• However , delayed manifestation of amniotic fluid embolism beyond 48
  hours after delivery is extremely rare, and thus this diagnosis is unlikely

Question 19

Pulmonary cause as the main mechanism of disease in this patient

Answer 19

• Very few indications of a pulmonary cause for Mariah’s presentation
• However , the presence of orthopnea , copious pink and frothy discharge ,
  bilateral pleural effusions , leg edema, elevated serum B type natriuretic
  peptide and troponin levels , along with tachycardia , cool extremities , and
  hypotension , together suggest pulmonary venous congestion
• Acute pulmonary edema complicates approximately 1 in 1000 pregnancies and could explain her symptoms

Question 20

Cardiovascular causes of dyspnea and hypoxemia in post partum

Answer 20

Common: Preeclampsia, iatrogenic fluid overload, edema associated with tocolysis, myocardial infarction, preexisting cardiac disease, peripartum cardiomyopathy
Rare: Septic cardiomyopathy, pericardial process, takotsubo cardiomyopathy, toxic cardiomyopathy (e.g. from alcohol or cocaine), thyrotoxicosis, aortic dissection, pericardial process, mitral valve chordal rupture (usually with mitral valve prolapse)

Question 21

Fluid overload as the diagnosis in this patient

Answer 21

• Iatrogenic fluid overload , which compounds ongoing reabsorption of
  extracellular fluids , is the leading cause of pulmonary edema post partum
• Women with this diagnosis usually have had a positive fluid balance of 3
  to 9 liters for the preceding 48 hours.
• Mariah was not reported to have received excess fluid administration

Question 22

How many pregnancies does pre-eclampsia affect?

Answer 22

3-5% of all pregnancies

Question 23

What are the hallmarks of pre-eclampsia? Mechanism of action?

Answer 23

The hallmarks are hypertension and proteinuria, which are most likely elicited by the secretion of antivascular factors from the placenta in late gestation

Question 24

Pulmonary edema in preeclampsia and its relevance in this patient

Answer 24

• Pulmonary edema is a frequent complication of preeclampsia
• Preeclampsia pulmonary edema often becomes evident post partum
• In this case , neither elevated blood pressure nor proteinuria was noted
  during or after pregnancy , including at the time of initial presentation
• Post partum preeclampsia cannot be ruled out, but it is a unlikely diagnosis

Question 25

Cause of pulmonary edema in pre-eclampsia

Answer 25

Pulmonary edema is multifactorial : endothelial damage confers a predisposition to vascular leak , diastolic dysfunction and acutely elevated blood pressure confer a predisposition to pulmonary venous congestion , and loss of serum protein lowers intravascular oncotic pressure.

Question 26

Risk of MI in pregnant woman

Answer 26

- The risk of myocardial infarction among pregnant or recently pregnant women is three times as high as that among nonpregnant women - Absolute incidence is <1/10,000 but climbs as maternal age increases - Spontaneous coronary artery dissection (sCAD) causes one third of acute MI in this population , mostly peripartum

Question 27

MI as a diagnosis in this woman

Answer 27

In this patient , absence of ECG changes , normal serum creatine kinase level , and the only slightly elevated serum troponin level , make this diagnosis unlikely , although it cannot be ruled out. Indeed , MI could have occurred days before the presentation

Question 28

Risks associated with Mariah being from South America

Answer 28

Mariah is from South America, which places her at risk for Chagas ’ cardiomyopathy , rheumatic heart disease , or both

Question 29

Cardiac symptoms of Chaga's

Answer 29

Cardiac rhythm abnormalities, myocardial abnormalities, aneurysms, and thromboembolism

Question 30

Effect of pregnancy on cardiovascular system and how a preexisting's heart condition might be the cause of Maria's symptoms

Answer 30

- Pregnancy generates profound hemodynamic changes , including increases in total blood volume, cardiac output , and cardiac work. - Underlying cardiac disease is frequently aggravated or unmasked by pregnancy - However , hemodynamic changes of pregnancy primarily occur during the first two trimesters , and clinical presentation with heart failure typically occurs during this time, unlike the timing in this patient

Question 31

What is peripartum cardiomyopathy and what is it characterized by?

Answer 31

- Idiopathic form of cardiomyopathy presenting with heart failure towards the end of pregnancy, or in the months following delivery - Peripartum cardiomyopathy is characterized by congestive heart failure and left ventricular systolic dysfunction toward the end of pregnancy or after delivery, in the absence of other identifiable causes of cardiac disease or heart failure - It is a diagnosis of exclusion

Question 32

Ejection fraction in peripartum cardiomyopathy

Answer 32

The ejection fraction on echocardiography is nearly always less than 45%

Question 33

This patient's likelihood of peripartum cardiomyopathy

Answer 33

Mariah’s hypotension and evidence of peripheral vasoconstriction suggest a state of low cardiac output , which in the absence of a more likely explanation , could indicate a diagnosis of peripartum cardiomyopathy

Question 34

Causes of heart failure among female patietns

Answer 34

Most common is peripartum cardiomyopathy followed by hypertensive heart disease then rheumatoid heart disease

Question 35

Timing of peripartum cardiomyopathy

Answer 35

Over 90% of cases are manifested in the first weeks postpartum , as in this case

Question 36

Manifestations of peripartum cardiomyopathy

Answer 36

The manifestation is similar to that of other cardiomyopathies , including dyspnea , orthopnea , edema , and , in extreme cases as in this patient ), hypoxemia * B type natriuretic peptide levels do not normally rise during pregnancy but are typically elevated in peripartum cardiomyopathy , as are troponin levels * Chest radiographs typically show cardiomegaly , as in this case, although peripartum cardiomyopathy can occur without cardiac dilatation

Question 37

Top diagnosis in this patient

Answer 37

- Because of the initial clinical presentation , peripartum cardiomyopathy is at the top of the list in differential diagnosis - However , should also consider ACS and coronary artery dissection

Question 38

Hemodynamic changes postpartum

Answer 38

Cardiac output is high and systemic vascular resistance low

Question 39

When is the peripartum cardiomyopathy most likely to happen?

Answer 39

In the first month following pregnancy

Question 40

Risk factors for PPCM

Answer 40

- Remain poorly understood, most cases are idiopathic - Include: advanced age >30 multiparity, African descent, multiple gestation, obesity, preeclampsia/eclampsia, hypertension ,prolonged (>4 weeks) tocolysis (medications used to suppress premature labor) with beta agonists - Myocarditis, autoimmune. and hemodynamic factors are invloved

Question 41

Probability score of PPCM

Answer 41

Fett and colleagues developed a scoring system, with symptoms and signs each having a possibility of 2 points including dyspnea, orthopnea, unexplained cough, pitting edema, weight gain 9th month, and palpitations - 0-2 is low risk (monitor), 3-4 mild risk (consider blood BNP), and 5 or higher is high risk (blood BNP and echo)

Question 42

Cause of PPCM

Answer 42

Research suggests that peripartum cardiomyopathy is triggered by insults to the cardiac vasculature that occur during late pregnancy and the postpartum period including inappropriate cleavage in the heart of circulating prolactin into a potently antivascular fragment and the secretion of sFlt 1 from the late gestational placenta - Prolactin and sFlt 1 begin to circulate late in pregnancy, which may explain the timing of peripartum cardiomyopathy. - Bromocriptine has shown to reduce serious symptoms and death

Question 43

How is diagnosis of peripartum cardiomyopathy made

Answer 43

ECG, BNP, Echo

Question 44

Medications to manage cardiomyopathy in pregnancy

Answer 44

Early pregnancy- Diuretics, hydralazine, beta blocker Late pregnancy- Diuretics, hydralazine, beta blocker Postpartum- Diuretics, ace inhibitors, beta blocker

Question 45

Bromocriptine dose for PCMM

Answer 45

2.5mg x2/d for 2 weeks then 2.5mg/day for 6 weeks

Question 46

Prognosis of peripartum cardiomyopathy

Answer 46

- prognosis related to LV recovery - 50% recover baseline function within 6 months

Question 47

Risk in subsequent pregnancies in PPCM

Answer 47

- 50% will show further deterioration in LV dysfunction in those with persistent LV dysfunction - 25% will die in those with persistent LV dysfunction - 50% will have premature delivery and abortion in those with persistent lv dysfunction - 20% will have a relapse if they completely recovered - Likley to have a normal susbequent pregnancy in those who fully recovered from first one - Better prognosis in SSP in those who completely recovered vs those with persistent LV dysfunction