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Case report 3

Tendi Robby Setia

RSUD WALED CIREBON
 IDENTITAS PASIEN

 Nama : Ny DA

 Usia : 29 tahun

 Agama: Islam

 Suku : Jawa

 Status pernikahan : Menikah

 Alamat: hulubanteng pabuaran

 Pekerjaan : ibu rumah tangga

 Masuk RS : 4 januari 2017

 

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Keluhan utama :
 Sesak nafas setelah 2 bulan melahirkan

 Riwayat Penyakit Sekarang :

 2 bulan SMRS os mulai merasakan sesak nafas, sesak nafas bertambah dengan aktifitas
ringan seperti mandi atau berjalan kurang lebih 10 meter, keluhan sedikit berkurang dengan
istirahat, pasien juga merasakan tiba-tiba terbangun pada malam hari karena sesak, dan
lebih nyaman bila tidur dengan dua bantal. Pasien juga merasakan lemas, pegal seluruh
badan, berat badan yang turun dengan cepat, pusing, berdebar-debar, berdebar – berdebar
yang dirasakan sebabkan os tidak dapat tidur, nyeri dada yang menyebar sampai punggung
dan ke pergelangan tangan, napsu makan menurun. Pasien tidak mengeluh adanya batuk.

 3 hari SMRS os merasakan sesak napas yang semakin memberat, lemas yang memberat,
dada berdebar-debar, tidak bisa tidur, nyeri dada baik kiri dan kanan yang menjalar sampai
ke punggung, os juga merasakan pegal seluruh badan. Terdapat edema di ke dua tungkai
pasien.
 Os baru melahirkan anak pertama secara spontan pervaginam pada bulan oktober 2017,
anaknya lahir dalam keadaan sehat. Keluahan sesak nafas dirasakan sejak 2 bulan pasca
melahirkan anak pertama. Selama trimester I, II, dan III kehamilan anak ketiga os tidak
pernah merasakan sesak maupun nyeri dada. Selama masa kehamilan pasien memeriksakan
kandungannya secara teratur di puskesmas.

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 Riwayat persalinan

os melahirkan dengan persalinan induksi pervaginam di RSUD WALED,rujukan

dari puskesmas dengan kehamilan cukup bulan Ketuban pecah dini

 Riwayat kehamilan

Saat usia 7 bulan Os dirawat karena prematur kontraksi

 Riwayat Penyakit Dahulu :

Riwayat Penyakit Jantung kongenital(-)HT-,DM-

Riwayat Penyakit Keluarga :

 Riwayat penyakit jantung (-)

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PEMERIKSAAN FISIK
Keadaan umum : tampak sakit ringan
Kesadaran : kompos mentis
TD : 120/70 mmHg, FN : 100 kali/menit, regular, isi cukup, FP :
30kali/menit S: 370C
BB : 46 kg TB : 150 cm, IMT : 20,44 kg/m2
Mata : konjungtiva pucat +/+, sklera ikterik -/-, pupil bulat isokor,
refleks cahaya normal.
Leher : kelenjar tiroid tidak teraba membesar, tidak terdapat
massa,KGB tidak membesar
Tekanan vena jugularis : 5-2 cmH2O
Thoraks : bentuk dan pergerakan simetris
Paru:suara napas vesikule kanan=kirir, ronkhi +/+, wheezing -/-
Jantung:BJ I- II reguler,kuat,cepat, Murmur (-), gallop (-)
Abdomen:datar,soepel,BU+normal,hepar dan lien tidak teraba
membesar
Ekstremitas: akral hangat.CRT<2s,oedem
 

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laboratorium
 Hb :11,9 Ureum :34
Kreatinin:1,1
 Ht:35

 Leuko:10.50 SGOT:17
SGPT :5.9
 Tombosit:382

 GDS:125

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Foto thorax

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1/17/18
diagnosa
 PPCM nyha fc grade 2

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Penatalaksanaan
Di IGD

 0ksigen 3lpm nasal kanul

 IVFD Nacl 0,9 /24 jam

 Kateter urin

 Furosemid 2 ampul

 Cefotaksim/24 jam

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Terapi di ruangan teratai

 02 3lpm nasl kanul

 Furosemid 40mg/12 jam

 Cefotaksim 1g/12 jam

Konsul Sp.PD

Jawaban konsul

 IVFD NaCl 0.9%/24 jam

 Diet jantung 1700 kkal/hari

 Furosemid 5mg/jam

 Spironolakton 25mg/24 jam

 ISDN 2X ½ tablet

 Bisoprolol 1x2,5mg

 Digoxin 2 x1/2 tablet

 Ramipril 1x6.25

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Follow up hari ke 2
 S:sesak berkurang,lemas+

 0:ku:sakit sedang,cm

tensi:110/80mmHg nadi:80x/menit S:36.5 respi:24x/menit urin output:1500cc/hari

Mata : konjungtiva pucat -/-, sklera ikterik -/-, pupil bulat isokor, refleks cahaya normal.

Leher : kelenjar tiroid tidak teraba membesar, tidak terdapat massa,KGB tidak membesar

Tekanan vena jugularis : 5-2 cmH2O

Thoraks : bentuk dan pergerakan simetris

Paru:suara napas vesikule kanan=kirir, ronkhi +/+, wheezing -/-

Jantung:BJ I- II reguler,kuat,cepat, Murmur (-), gallop (-)

Abdomen:datar,soepel,BU+normal,hepar dan lien tidak teraba membesar

Ekstremitas: akral hangat.CRT<2s,oedem

 O:PPCM

 P:terapi lanjutkan

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Follow up hari ke 3
 S:sesak berkurang,lemas-,nyeri ulu hati

 0:ku:sakit sedang,cm

tensi:110/80mmHg nadi:80x/menit S:36.5 respi:24x/menit urin output:1500cc/hari

Mata : konjungtiva pucat -/-, sklera ikterik -/-, pupil bulat isokor, refleks cahaya normal.

Leher : kelenjar tiroid tidak teraba membesar, tidak terdapat massa,KGB tidak
membesar

Tekanan vena jugularis : 5-2 cmH2O

Elektrolit
Thoraks : bentuk dan pergerakan simetris K:2.8

Paru:suara napas vesikule kanan=kirir, ronkhi -/-, wheezing -/-

Jantung:BJ I- II reguler,kuat,cepat, Murmur (-), gallop (-)

Abdomen:datar,soepel,BU+normal,NT+ di epigastrium,hepar dan lien tidak teraba

membesar

Ekstremitas: akral hangat.CRT<2s,oedem -/-

 O:PPCM

 P:-furosemid 40mg/12jam..OMZ 40mg/12 jam,KSR 2x1 tablet..lain-lain terapi

lanjutkan

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Follow up hari ke 4
 S:sesak-.lemas-

 0:ku:sakit sedang,cm

tensi:110/80mmHg nadi:80x/menit S:36.5 respi:24x/menit urin

output:2000cc/hari

Mata : konjungtiva pucat -/-, sklera ikterik -/-, pupil bulat isokor, refleks cahaya
normal.

Leher : kelenjar tiroid tidak teraba membesar, tidak terdapat massa,KGB tidak
membesar

Tekanan vena jugularis : 5-2 cmH2O

Thoraks : bentuk dan pergerakan simetris

Paru:suara napas vesikule kanan=kirir, ronkhi -/-, wheezing -/-

Jantung:BJ I- II reguler,kuat,cepat, Murmur (-), gallop (-)

Abdomen:datar,soepel,BU+normal,NT-.hepar dan lien tidak teraba membesar

Ekstremitas: akral hangat.CRT<2s,oedem

 O:PPCM

 P:terapi lanjutkan

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Follow hari ke 5
 S:sesak berkurang,lemas+

 0:ku:sakit sedang,cm

tensi:120/80mmHg nadi:80x/menit S:36.5 respi:24x/menit urin output:1500cc/hari

Mata : konjungtiva pucat -/-, sklera ikterik -/-, pupil bulat isokor, refleks cahaya normal.

Leher : kelenjar tiroid tidak teraba membesar, tidak terdapat massa,KGB tidak membesar

Tekanan vena jugularis : 5-2 cmH2O

Thoraks : bentuk dan pergerakan simetris

Paru:suara napas vesikule kanan=kirir, ronkhi -/-, wheezing -/-

Jantung:BJ I- II reguler,, Murmur (-), gallop (-)

Abdomen:datar,soepel,BU+normal,hepar dan lien tidak teraba membesar

Ekstremitas: akral hangat.CRT<2s,oedem

 O:PPCM

 P:BLPL

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 OBAT PULANG

-Furosemid 40mg-0-0

-spironolacton 25mg-0-0

-bisoprolol 2,5mg-0-0

-Ramipril 1x6.25

-OMZ 40mg 1-0-1

Kontrol poli 1 minggu

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 1/17/18

Peripartum
Cardiomiopathy
Definition
 Definition of PPCM based on the 2010 European Society of
Cardiology (ESC) Working Group:

 The development of sistolic heart failure toward the end of

pregnancy or in the month following pregnancy with left
ventricular ejection fraction (LVEF) generally less than 45 percent
in the absence of another identifiable cause of heart failure

 The etiology of PPCM is unknown

 Possible cause including angiogenic imbalance,altered prolactin

processing,genetic,inflammatory,hormonal,hemodynamic and
autoimmune factors

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Incidence of PPCM

USA
1:2500-4000 Japan
1:149

Pakistan
1:837
Haiti
1:300
Nigeria RSUD WALED
1:100 1:136
India
1:1374

South africa
1:1000

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 Mortality rate in USA 6%

 Mortality rate in developing countries(within 5

years):25%

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Risk factor
 Pregnancy induced hypertension

 Pregnancy with multiple fetus

 Older age (>30 years)

 Maternal cocaine abuse

 Long term (>4weeks)oral tocolytic therapy

with beta adrenergic agonists as terbutaline

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Diagnosis
 All of the following :

Classic
1. Development of heart failure (HF) toward the end of
pregnancy or in the following delivery
2. Non identifiable causes of heart failure
3. No recognizable heart disease prior to the last month of
pregnancy

Additional
Strict echocardiographic indication of left ventricular dysfunction
a. Ejection fraction (LVEF) nearly always less than 45 percent
b. Fractional shortrning < 30%
c. End diastolic dimension > 2.7 cm/m2

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Diagnostic testing

Complete family history,to identify famillial association

 Serum test

 Chest radiograph

 Electrocardiogram

 Transthoracic echocardiogram

 Cardiac MRI and/or endomyocardial biopsy(when

indicated)

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Diagnostic testing
Serum

 Complete blood cell count with differential

 Creatinine and urea levels

 Electrolyte levels,including magnesium and

calcium

 Levels of cardiac enzymes,including troponin

 Level of B-type natriuretic peptide

 Liver function and level of thyroid stimulating

hormone

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Chest Radigraph

Enlargement of the cardiac

Pulmonary venous congestion and/or interstitial

edema

Pleural effusions

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Electrocardiogram

Nonspesific-> sinus tachycardia(or rarely, atrial

fibrillation)& nonspesific ST and T

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Transthoracic
echocardiogram
Global reductionin LV systolic function with LVEF
nearly always <45 percent other possible
finding:LA enlargement,LV or left atrial trombus,
dilated RV, RV hypokinesis,mitral and tricuspid
regurgitation effusion

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Differential Diagnosis
 Pre exiting cardiomyopathy

 Pre exiting acquired or congenital valvular

heart disease unmasked by pregnancy

 Diastolic heart failure due to hypertensive

heart disease

 Myocardial infection

 Pulmonary embolus

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Management

 Similar to treatment for other types of heart failure,

 attention to particular risks during pregnancy including fetal risk

 ACE inhibitor,Angiotensin II blockers, Aldosteron are

contraindicated(grade1B)

GOALS:

 Relief sympotms

 Optimizing hemodynamics

 Continuation (or initiation) chronic therapies that prove long-term

outcomes

 Treatment of precipitating factors (eg; anemia, arrhythmias, infection,

thyroid disorder)
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Initial Assessment
 Airway: intubate promptly upon distress work
of breathing

 Breathing: provide suplemental oxygen,

continues pulse oxymetry, measure arterial
blood gases

 Circulation: cardiac & blood pressure

monitoring, insert artherial catheter, obtain
central venous access

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Pharmacological
 Intravenous loop diuretic
Furosemide dose depends on basic creatinin clearence
GFR 60ml/mnt: Furosemide 20-40mg IV/12-24hour
GFR <60ml/mnt: Furosemide 20-80mg IV/12-24hour

 Vasodilator

Nitroglycerine infusion 5-10mcg/min, titrate to clinical status

and blood pressure
Nitroprusside 0.1-5mcg/min (caution in antepartum woman)

 Positive inotropic agent

Milrinone 0.25-0.5mcg/kg/min
Dobutamine 2.5-10mcg/kg/min

*Avoid B-blocker in acute phase  decrease perfusion 1/17/18

Treatment of heart failure

CO=HR x SV

preload Diuretics,nitrates,ACE
inhibitor

Afterload ACE Inh,dihydralazine

VF threshold
Beta-blockers

LV remodelling
Aldosterone ant

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Antepartum
 Nonpharmaceutical therapy:
Low sodium diet: limit 2 gram/day
Fluid restriction: 2 L/day
Light daily activity
 B-blocker

Carvedilol
 Vasodilator

Hidralazine

 Digoxin

 Thiazide diuretic

Hidrochlorothiazide 1/17/18
Postpartum
 ACE inhibitor  Vasodilator

Captopril Hidralazine
Enalpril Isosorbid

 ARB  Aldosteron antagonist

Candesartan Spironolacton
Valsartan Eplerenon

 Loop diuretics  B-blocker

Furosemide  Warfarin if EF 35%

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Antithrombotic Therapy
 Patients with PPCM are at high risk for
thrombus formation and thromboembolism due
to both the hypercoagulable state of pregnancy
and stasis of blood due to severe LV
dysfunction

 Indicated if there are left ventricular thrombus

evidence of systemic embolism
Mechanical Circulatory
Support & Cardiac
Transplantation
 Potential treatment options when HF is
refractory to conventional therapy
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Breastfeeding & contraception
 Women who are clinically stable should be
discouraged from breastfeeding as long as it is
compatible with their heart failure medications

 PPCM with persistent left ventricular(LV)

disfunction or LV ejection fraction(LVEF)<25%
at diagnostic are at high risk of recurren
PPCM.future pregnancy should be avoided

 Sterilization procedure or non estrogen method

of contraception, such as the etonogestrel
implant,IUD.levonogestrel-releasing IUD are
suggested

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Delivery
 Prompt delivery is sugested in women with
PPCM with advanced HF

 Early delivery is not required if the maternal

and fetal condition are stable

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references
 Cunnngham G F, Leveno J K,Bloom L S,et all. Williams
Obsetrics 24th Edition.New york McGraw Hill education

 Silwa K,Hilfiker-Kleiner D,Petrie MC,et al.Current state of

knowledgeon etiology,diagnosis,management,and
therapy of peripartum cardiomiopathy: a position
statement from the heart failure Association of The
European Society of Cardiology Working Group on
peripartum cardiomiopathy. Eur J Heart Fail 2010 12:767

 Dunlay SM,Roger VL,Weston SA,et al 2013ACCF/AHA

guideline for management heart failure

 Indeks insidensi angka melahirkan,PPCM dan hipertensi

dalam kehamilan2017,rekam medis RSUD WALED
CIREBON

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