Online Clinical Case Study (September 2009)
The
content of the Office Cardiology Series is provided by:
Dr. LI Siu Lung, Steven FHKAM (Med), FRCP (Glasg), FRCP (Edin), FRCP (Lond),
Specialist in Cardiology.
Dr. WONG Shou Pang, Alexander FRCP, FHKAM (Med.), FHKCP, Specialist in Cardiology.
臨床心臟科個案研究之內容誠蒙李少隆醫生及王壽鵬醫生提供。
A 35-year-old lady is seen for shortness of breath. She had been discharged from hospital the previous day, 4 days after Caesarean section (inadequate maternal effort) for a pair of twin babies at full term. This was her first pregnancy and she had developed some ankle oedema and fatigue in her last week of pregnancy. She exhibited some persistent shortness of breath after delivery and had developed orthopnea last night. She is a non-smoker in good previous health, and her antenatal period has been uneventful apart from mild gestational hypertension. Physical examination revealed a raised JVP with bilateral basal crepitation and ankle oedema. Her resting oxygen saturation with room air is only 89% and she is tachypneic.
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What is the likely
diagnosis? |
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| 2. |
What
are the usual risk factors for this condition? |
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What is the most useful
investigation? |
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What is the mortality
rate of this condition? |
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Peri-partum cardiomyopathy is a form of dilated cardiomyopathy. The syndrome has four criteria: 1) development of heart failure in last month of pregnancy and within 5 months of delivery; 2) no other identifiable cause of heart failure; 3) no recognizable heart disease prior to the last month of pregnancy; and 4) echocardiographic documentation of impaired left ventricular systolic function. The incidence is around 1:4,000 to 1:15,000. The mortality rate varies from 10% to 30%. It can occur at any age but is more common in women older than 30 years. In most cases, it involves the first and second pregnancies. It is also associated with gestational hypertension, twin pregnancy and the use of tocolytic therapy. The clinical features are those of congestive heart failure, which are indistinguishable from other forms of dilated cardiomyopathy. The treatment of choice is the same as for other forms of congestive heart failure and includes oxygen, diuretic therapy, ACEI, beta-blockade, digoxin and, rarely, inotropic support, ventilator therapy and IABP support in extreme cases. The clinical course varies, but about 50%–60% patients show complete or almost complete recovery within the first 6 months post partum. Others may have persistent left ventricular dysfunction and chronic heart failure of varying degrees. In extreme cases, premature death is seen and cardiac transplantation has been reported in some cases. Subsequent pregnancies are usually associated with relapse. The likelihood is greater in those with persistent left ventricular dysfunction but it is also possible in those who have completely recovered. The mortality rate of relapse can be as high as 19%–25% in those with incomplete recovery of left ventricular function. Therefore, in general, subsequent pregnancies are discouraged. |
A 9-year-old girl noticed she had asymptomatic white patches on her face for a few months. Physical examination revealed several ill-defined hypopigmented patches on her cheeks, with fine scales on the surface. Her parents were worried it was vitiligo.
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The
content of the Dermatology Series is provided by: |
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