Key Points

1. Stabilize and Transfer if necessary
2. Assess for dilated cardiomyopathy and hypertrophic heart disease
3. Symptoms: shortness of breath wheezing, palpitations, edema, chest pain, dizziness, or extreme fatigue.
4. Signs: may include hypertension (>140/90), tachycardia (>120), rales, +S3, and oxygen saturation <90%
5. Assess: EKG, BNP, troponin, echocardiogram, chest x-ray
6. Manage: stabilize, consulate MFM/Cardiology, transfer if necessary
7. Presents to the ER multiple times with shortness of breath or other vague symptoms; needs work up including echocardiogram (BNP and troponin when not readily available)

Synopsis

Cardiomyopathy is one of the leading causes of maternal mortality. Two subtypes include dilated cardiomyopathy and hypertrophic heart disease. Other cardiovascular diseases include Pulmonary hypertension, Aortic dissection, Unexplained sudden death, probable arrhythmia, Congenital heart disease, non-valvular, Coronary artery disease, and Valvular disease. Risk factors include obesity, African-American race/racism, hypertension during pregnancy, and illicit drug use (methamphetamine, cocaine). Symptoms include shortness of breath wheezing, palpitations, edema, chest pain, dizziness, or extreme fatigue. Signs may include hypertension (>140/90), tachycardia (>120), rales, +S3, and oxygen saturation <90%. Assessment includes diagnostic tools (EKG, BNP, echocardiogram, chest x-ray). Treatment includes consultation with cardiology and maternal-fetal medicine, stabilization, and targeting the underlying cause.

Questions to ask:

• Worsened exercise tolerance
• Unexpected fatigue, difficulty with daily tasks
• Symptoms that are worsening, especially chest pain, palpitations, or dizziness
• New onset of cough or wheezing (adult-onset asthma is rare)
• Lower extremity edema (improving or worsening)
• Orthopnea, how many pillows
• Failure to lose weight or unusual weight gain
• A history of cardiopulmonary conditions
• A history of substance abuse or cigarette use

Management

Monitor oxygen saturation, vital signs, and cardiac rhythm. Provide supplemental oxygen and assisted ventilation as needed. Place two intravenous catheters and position the patient upright. Provide non-invasive ventilation unless immediate intubation is required. Initiate loop diuretic therapy to relieve congestion/fluid overload (i.e., Furosemide). Hemodynamic support with inotropes and vasopressors if required. Follow recommended guidelines for either systolic or diastolic heart failure management. Additionally, arrhythmias can be present with peripartum cardiomyopathy, and consideration of an antiarrhythmic medication or implantable cardioverter-defibrillator (CD) and resynchronization therapy is necessary. Peripartum women are also at high risk from VTE and may warrant prophylaxis.