Journal of Clinical Studies & Medical Case Reports Category: Medical Type: Case Report
Sudden Death of a Woman at Postpartum Period - Myocarditis Related with Peripartum Cardiomyopathy: Autopsy Diagnosis, Case Report
- Burcu Kasap1*, Emre Canverenler2, Kenan Karbeyaz3, Yasemin Balci4, Melike Erbas3
- 1 Department Of Obstetrics And Gynecology, School Of Medicine, MuglaSitkiKocman University, Mugla, Turkey
- 2 Department Of Obstetrics And Gynecology, Sinop State Hospital, Sinop, Turkey
- 3 Justice Ministry, Institute Of Forensic Medicine, Eski?ehir, Turkey
- 4 Department Of Forensic Medicine, School Of Medicine, Institute Of Forensic Medicine, MuglaSitkiKocman University, Mugla, Turkey
*Corresponding Author:Burcu Kasap
Department Of Obstetrics And Gynecology, School Of Medicine, MuglaSitkiKocman University, Mugla, Turkey
Received Date: Dec 30, 2014 Accepted Date: Feb 25, 2015 Published Date: Mar 11, 2015
A 29-year-old woman underwent cesarean section for twin pregnancy due to previous cesarean section operation. The patient died suddenly at postpartum eight day and the medico-legal autopsy results revealed ‘focal myocarditis’. Since the patient had no symptoms or signs of a cardiac disorder during the hospitalization, focal myocarditis was regarded as a complication rather than the cause. Herein we report the sudden death of a woman at postpartum period and discuss the differential diagnosis by reviewing the related literature.
Maternal mortality is the death of a woman during pregnancy and within 42 days after delivery. The most frequent direct or indirect diagnoses associated with maternal mortality are; pregnancy-induced hypertension, pulmonary embolus, amniotic fluid embolus, hemorrhage and cardiac disease . The distribution of cardiac disease related maternal deaths differ in reasons from country to country. Myocardial infarction, cardiomyopathy and Congenital Heart Diseases (CHD) are the leading causes in western countries whereas rheumatic heart diseases are accused mostly in developing countries . The incidence of cardiovascular diseases in pregnancy is about 2-4% . Myocarditis is the inflammation of the myocardium due to variable etiologies and 2.5% of the maternal deaths were caused by myocarditis or myocardial fibrosis . Herein we present a rare case of sudden maternal death which was complicated with ‘focal myocarditis’ according to autopsy report.
Myocarditis is inflammation of the cardiac muscle and is caused by viruses, bacteria, parasites or fungi, and by toxic materials, or by an unknown origin. Myocarditis has a wide spectrum of clinical courses from full recovery to serious complications including permanent cardiac damage or sudden death by fatal arrhythmic events . Myocarditis is a major cause of sudden unexpected death in infants and young adults .
Sudden Adult/Arrhythmic Death Syndrome (SADS) is the death of an adult in which no any cause can be identified and it is reported to be the most common cause of cardiac maternal deaths . SADS is also associated with obesity, cardiac hypertrophy, atherosclerosis and high circulating non-esterified fatty acid concentrations . The present case was asymptomatic by means of a cardiological disorder and the only identified risk factor for SADS was a BMI of 35 kg/m2.
Peripartum Cardiomyopathy (PPCM) is cardiac failure in the last month of pregnancy or within five months after delivery in the absence of underlying heart disease . It is very rare and occurs in one of 3000-4000 pregnancies. PPCM associated risk factors were advanced maternal age, obesity, chronic hypertension, multiparity, multiple gestation, prolonged to colysis with beta-adrenergic agonists and preeclampsia . The patient had multiple risk factors for PPCM including twin pregnancy, multiparity, and obesity. The underlying mechanisms of PPCM were poorly understood. But myocarditis in PPCM is well described as a mechanism for heart failure and has been demonstrated on endomyocardial biopsy studies . In animal models of PPCM bromocriptine which is a prolactin release inhibitor, was found to have hopeful results in both prevention and treatment of this catastrophic disorder . In the present case maternal mortality occurred in the 8th postpartum day and in breastfeeding period during when prolactin levels are very high. Most women present in the first month postpartum with typical heart failure symptoms such as dyspnea, lower extremity edema, and fatigue. But the patient had no specific symptoms related with heart failure. Also, histopathological autopsy examination reported pulmonary congestion, intra alveolar edema, cardiac congestion, perivascular, interstitial edema and focal myocarditis. These findings also strengthen our suspicion for PPCM. But in the macroscopic report, there were no any findings that can support the presence of dilated Cardiomyopathy.
In conclusion, the present case was asymptomatic by means of a cardiological disorder and the only risk factors were multiple pregnancies, multiparity and a BMI of 35 kg/m2. The probable cause of death was regarded as ‘focal myocarditis’ according to histopathological findings of autopsy and myocarditis which is documented in the autopsy report of the present case may actually be a complication in this patient rather than the cause of death.
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Citation: Kasap B, Canverenler E, Karbeyaz K, Balc? Y, Erba? M (2015) Sudden Death of a Woman at Postpartum Period - Myocarditis Related with Peripartum Cardiomyopathy: Autopsy Diagnosis, Case Report. J Clin Stud Med Case Rep 2: 009.
Copyright: © 2015 Burcu Kasap, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.