Author Information
Chakre Shila*, Pardeshi Sachin**, Warke HS***, Mayadeo NM****
(* Assistant Professor, **
Assistant Professor, *** Associate Professor, **** Professor
Department of Obstetrics and
Gynecology, Seth G.S.
Medical College
and K.E.M Hospital,
Mumbai, India.)
Abstract
Constrictive pericarditis is a rare occurrence
in pregnancy. It occurs in developing countries commonly due to tuberculosis,
whereas in the developed countries it is due connective tissue disorders,
idiopathic and post surgical injuries.[1,2] Our case report presents
medical management of a 26 years old multigravida, a diagnosed case of
constrictive pericarditis secondary to tuberculosis which was diagnosed 5 years
ago.
Introduction
Constrictive pericarditis is a disorder in which
a chronically thickened and fibrotic pericardium limits cardiac fillings.
Patients with severe constrictive pericarditis usually have a limited stroke
volume caused by poor diastolic filling. It is a serious threat to both, the
pregnant woman and the fetus.
Case report
A 26 years old gravida 2, para one, living one
with previous full term normal delivery 6 years back was admitted at 35 weeks
of gestation for evaluation of IUGR. She was diagnosed to have pulmonary
tuberculosis 5 years ago and abdominal tuberculosis 3 years ago for which she
was treated. Patient presented with grade II dyspnea with cough one and half
years ago. On evaluation, CT scan showed calcified pericardium suggestive of
constrictive pericarditis. Patient was following with cardiologist. An
echocardiogram was suggestive of trivial TR with septal bounce with pericardial
calcification of left free side wall with ejection fraction of 60%. She was
treated with diuretics and was advised pericardiectomy. Patient was not willing
for surgery. Subsequently patient did not follow up.
The patient directly came after one year for
antenatal registration at 35 weeks of gestation at our institute and was
admitted for evaluation. In this pregnancy, on physical examination she was
comfortable. Blood pressure was 110/70 mm of Hg. Heart rate was 66 beats per
minute and regular. Respiratory rate was 24/min. Jugular venous pressure was 8
cm of water. On cardiac examination, there was gallop rhythm with pericardial
knock without murmur. On abdominal examination, uterus was 30 weeks of
gestation. There was lag of five weeks of gestation by her date. Patient had
mild bilateral ankle edema which was pitting in nature. Her electrocardiogram
showed nonspecific ST-T wave abnormality. Patient was managed with diuretics
and bed rest as per cardiologist opinion.
The patient went into spontaneous preterm labor
at 36 weeks of gestation. Patient was given cephalosporin, gentamycin and
metronidazole for preventing infective endocarditis. Patient progressed well in
labor. Her second stage of labour was cut short by outlet forceps application.
No ergometrin was given. Fluids were restricted to prevent overload. Injection
Lasix 40 mg was given after delivery as per cardiologist opinion. Male baby of
1.7 kg with 9/10 Apgar score was delivered. Patient and baby were discharged on
the third postpartum day after cardiologist opinion on diuretics.
Discussion
This is a rare case of constrictive pericarditis
secondary to tuberculosis in pregnancy.[3]
Constrictive pericarditis is the end stage of the healing process
of inflamed pericardium which takes several months to years for dense fibrosis
and calcification. Scarring results in severe restriction of filling of all the
cardiac chambers and orifices of great vesseles which produces signs and
symptoms of chronic constrictive pericarditis.[1]
There is increased cardiac output of 40 to 50%
in pregnancy and 50% in active labour. Patients with constrictive pericarditis
have poor diastolic filling pattern with raised atrial pressure. [1] Compensation
occurs by increase in heart rate. Restricted atrial distensibility presents
significant rise in atrial natriuretic factor which leads to sodium and water
retention and high systemic venous pressure, contributing to high hepatic
venous pressure resulting in ascites and
edema.[4] Dyspnea, fatigue, palpitation and edema are common
symptoms of constrictive pericarditis.[5] In pregnancy, initial
stage of the disease can be managed conservatively by salt restriction and
diuretics but ultimately surgery should not be delayed.[1 ] Preoperatively
diuretics should be started to reduce jugular venous pressure, edema feet and
ascites.[1] Beta-adrenergic blockers and digoxin are only used for
control of atrial fibrillation.[6]
This case is an example of conservative
management of constrictive pericarditis during pregnancy with definitive plan
of pericardiectomy after delivery.
References
1.
R K Gokhroo, Rahul Gokhroo. Pericardial
diseases. In Prof M Khalilullah and Prof. S
K Khanna, editors. Cardiology. 1st ed. New Delhi: The Heart Centre 2012; pp.
266-303.
2.
Noble O Fowler. Cardiac diagnosis and
treatment. 3rd ed. Philadelphia:
Harper and Row publications; 1980; pp. 997-1005.
3. Probst R, Mier T.
Acute pericarditis complicating pregnancy. Obstet Gynecol 1963;22:393.
4.
David H Spodick. Pericardial diseases. In Eugene Braunwald,
Douglas P , Zipes, Peter Lobby,
editors. Heart Disease - A textbook of cardiovascular medicine. 6th
ed. Philadelphia, Pennsylvania: W B Saunders Company 2001; pp.
1849-1864.
5.
Ralph
Shabeti. Diseases of the pericardium. In R Wayne Alexander, Robert C
Schlant, Valentin Fuster, editors. Hurst’s The Heart. 9th
ed. McGraw-Hill 1998; pp. 2186-2191.
6.
Benjamin P. Sachs, Beverly H
Lorell, Mary Mehrez, Natalio Damien. Constrictive pericarditis and pregnancy.
Am J Obstet Gynecol 198;154:156-7.
Citation
Chakre
S, Pardeshi S, Warke HS, Mayadeo
NM. Pregnancy in a case of Constrictive
pericarditis. JPGO 2014 Volume 1 Number 2 Available from: http://www.jpgo.org/2014/02/pregnancy-in-case-of-constrictive.html