Question 28

College answer

a)
• Onset of heart failure in the last month of pregnancy or within 5 months post-partum
• Absence of an identifiable cause of heart failure
• Absence of recognizable heart disease prior to the last month of pregnancy
• LV systolic dysfunction demonstrated by classical echocardiographic criteria. The latter 
may be characterized as an LV ejection fraction < 45%, fractional shortening < 30%, or 
both, with or without an LV end-diastolic dimension 2.7 cm/m2 body surface area. (This 
level of detail not expected)

b)
i. List six important risk factors 
• Precipitous or tumultuous labour.
• Advanced maternal age.
• Caesarean and instrumental delivery.
• Placenta previa and abruption.
• Grand multi-parity (≥5 live births or stillbirths), 
• Cervical lacerations.
• Foetal distress.
• Eclampsia.
• Medical induction of labour.
• Polyhydramnios

ii. Outline the important clinical features of amniotic fluid embolism 
• The onset of the symptoms and signs of amniotic fluid embolism syndrome 
(AFES) most commonly occurs during labour and delivery, or immediately 
postpartum
• Non-specific symptoms – chills, nausea, vomiting, agitation
• Hypotension due to cardiogenic shock
• Hypoxemia and respiratory failure
• Disseminated intravascular coagulation
• Coma or seizures

Discussion

a)

In actual fact there are several competing definitions, of which the college offers one which is probably the least vague. Here is a table from  the ESC statement (Sliwa et al, 2010)

Characteristic features of peripartum cardiomyopathy (also from Sliwa et al):

• It is usually a postpartum process: only 9% present antepartum. NHL-BIOR definition calls it PPCM if it is one month before or five months after delivery, but the ESC people felt this (totally arbitrary) timeframe would lead to underdiagnosis.
• There is mainly LV dysfunction
• The LV is usually dilated (if it is dilated beyond 60mm, the chances of recovery are small)
• It usually gets better: An estimated 23%-54% of patients show complete recovery of their systolic function within 6 months.

b)

To mix up the college answer with an article by Knight et al (2012)

• Precipitous or tumultuous labour.
• Ethnic minority background
• Emergency delivery
• Smoking during pregnancy
• Diabetes
• Socioeconomic disadvantage
• Age over 35 (what the college describes as "advanced maternal age", otherwise known as "checkout time" )
• Caesarean and instrumental delivery.
• Placenta previa and abruption.
• Grand multi-parity (≥5 live births or stillbirths), 
• Cervical lacerations.
• Foetal distress.
• Eclampsia.
• Medical induction of labour.
• Polyhydramnios

Cardinal clinical features:

• Shock
• Hypoxia
• Altered mental status
• DIC

Other associated features are listed by Moore et al (2005):

• Seizures
• Confusion
• Agitation
• Foetal distress
• Fever
• Rigors
• Nausea / vomiting
• Headache