This question relates to the critically ill obstetric patient.
a) List the diagnostic criteria for peri-partum cardiomyopathy. (30%marks)
With respect to amniotic fluid embolism (AFE):
i. List six important risk factors.(30% marks)
ii. Outline the important clinical features.(40% marks)
• 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)
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.
• Medical induction of labour.
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
• Non-specific symptoms – chills, nausea, vomiting, agitation
• Hypotension due to cardiogenic shock
• Hypoxemia and respiratory failure
• Disseminated intravascular coagulation
• Coma or seizures
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.
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
- 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.
- Medical induction of labour.
Cardinal clinical features:
- Altered mental status
Other associated features are listed by Moore et al (2005):
- Foetal distress
- Nausea / vomiting
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