CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 6, November/December 2011
338
AFRICA
investigations and results are listed in Table 1.
Treatment included intravenous (iv) furosemide 20-mg bolus,
then 20 mg 12 hourly, iv magnesium sulphate (MgSO
4
) 4-g
bolus then 5 g in 500 ml 0.9% saline to run over five hours for
five doses. Also, iv hydralazine 5-mg bolus over 15 minutes, to
repeat if systolic and diastolic blood pressure are
≥
160 and 110
mmHg, respectively, intra-nasal oxygen at 6 l/min and nursed in
the cardiac position.
Some improvements in clinical condition were observed
about eight hours after commencement of therapy. The respira-
tory rate reduced to 36/min, the diastolic blood pressure reduced
to less that 100 mmHg and the chest became clearer, however
some episodes of foetal tachycardia were observed. Following
the improvement in cardiac symptoms, the decision was taken to
urgently deliver the baby by Caesarian section. The anesthetist
was informed, and in view of the urgency involved, no invasive
monitoring could be provided.
On arrival in the operating room, her blood pressure was
119/86 mmHg, pulse rate was 102 bpm, and oxygen saturation
was 98%. On auscultation, she still had a few crepitations in
both lung bases bilaterally. Peripheral venous cannulation was
done with an 18-guage iv cannula and a 0.9% saline infusion
was started. ECG leads, a pulse oximetry probe and non-invasive
blood pressure cuff were attached for continuous monitoring.
In view of the cardiac condition and the desire of the obste-
trician to urgently deliver the baby, combined spinal–epidural
(CSE) was chosen. After preloading with 250 ml of 0.9% saline
over 30 minutes, CSE was performed at the L4–L5 interspace
in the sitting position; 25 μg of fentanyl was injected through a
27-guage 120-mm Sprotte needle into the cerebrospinal fluid,
which was introduced through a 16-guage Tuohy needle.
An epidural catheter was inserted through which two doses
of 5 ml of 0.5% plain bupivacaine was administered. The patient
was placed in the supine position and a wedge was placed under
the right hip to minimise aorto-caval compression. Oxygen was
administered with a facemask at a flow rate of 5 l/min. The upper
levels of sensory block obtained were T8 at three minutes and T6
at five minutes; 250 ml of 0.9% saline and 500 ml of pentastarch
were administered intra-operatively to treat hypotension. A vaso-
pressor was not administered.
The operation proceeded uneventfully and a healthy female
baby of 1.45 kg was delivered eight minutes later (Apgar score
9/10). Intravenous oxytocin 10 mg was administered slowly at
the delivery of the placenta and 30 mg was put into 500 ml of
0.9% saline to run as an infusion for five hours. The patient was
haemodynamically stable throughout the procedure. The surgery
lasted 30 minutes and estimated blood loss was 500 ml.
The patient’s husband declined admission to the intensive care
unit because of financial constraints; hence the patient remained
under high-dependency care in the labour ward. Epidural analge-
sia was employed for the first 14 hours post-operatively.
Discussion
Although the aetiology of peripartum cardiomyopathy is uncer-
tain, viral, autoimmune and idiopathic causes have been consid-
ered.
9
Some cases of PPCM are being postulated to be part of the
spectrum of familial dilated cardiomyopathy (DCM) presenting
in the peripartum period.
10
It is usually a diagnosis of exclusion,
however there is an increased incidence of PPCM with multi-
ple gestation, pre-eclampsia, obesity, advanced maternal age,
11
African descent and prolonged tocolysis.
12
Worldwide, the frequency of peripartum cardiomyopathy
is highest where a large proportion of the women are of
African descent, such as Nigerian, Haitian and South African.
13,14
The lowest frequency of peripartum cardiomyopathy has been
reported in studies where women of African descent were less
common.
15,16
The highest reported incidence is in Nigeria, at
980 out of 100 000 deliveries.
17
This very high incidence may
be related to a local custom of ingesting salt in the postpartum
period, which increased the detection of peripartumn cardio-
myopathy by increasing heart failure symptoms.
17
Desai
et al
.
14
found a case incidence of 100 out of 100 000 deliveries in South
Africa. Fett
et al
.
13
reported an incidence in a predominately rural
population in Haiti of 334 out of 100 000 deliveries. The high
incidence of PPCM in our region requires that peri-operative
management of this subset of patients be well reported.
The presence of PPCM in a parturient requires expert
anaesthetic management for labour or for Caesarean section.
Aggressive pain management for labour is indicated to keep the
heart rate and systemic vascular resistance under control and to
attenuate the volume overloading effect of each uterine contrac-
tion.
18
The literature regarding the anaesthetic management of
peripartum cardiomyopathy is sparse, although several anaes-
thetic options for CS have been reported. These include general
anaesthesia (GA) with inhalational agents,
19
general anaesthesia
with remifentanil,
20
epidural anaesthesia,
21
spinal anaesthesia,
22
and combined spinal–epidural anaesthesia (CSE).
23
Considerations for regional anaesthesia in patients with
PPCM are similar to those with other causes of heart failure.
With regard to anaesthesia for Caesarean section, general
anaesthetic techniques involve drugs, which cause myocardial
depression and reduced systemic vascular resistance (SVR); and
positive-pressure ventilation, which decreases the venous return
to the heart. Also, the effects of stimulation of the sympathetic
nervous system following laryngoscopy and endotracheal intu-
bation may be inimical for a failing heart. General anaesthesia
may be necessary for urgent CS.
24
However, performing a rapid-
sequence induction on a patient with compromised cardiac func-
tion can be very challenging. When time permits, a carefully
administered regional anaesthetic seems to be advantageous.
In addition to avoiding the stress of GA, the vasodilatation
produced by regional anaesthesia is beneficial with isolated left
ventricular dysfunction.
25
The goals during the management of
anaesthesia in patients with cardiomyopathy include avoidance
of drug-induced myocardial depression, maintenance of normo-
TABLE 1. HAEMATOLOGICALAND
BIOCHEMICAL INVESTIGATIONS
Investigation/test
Before surgery After surgery
Packed cell volume (PCV)
47%,
34%
White cell count (WBC)
15 400/cm
Platelet count
136 000/
m
l
International normalised ratio (INR)
1.1
Serum electrolytes
potassium
5.2 meq/l
3.3 meq/l
sodium
134 meq/l
135 meq/l
bicarbonate
17 meq/l
18 meq/l
urea
31 mg/dl
51 mg/l
creatinine
1.0 mmol/dl
0.9 mmol/l
