Heart Pulmonary Arteries Fx dilated LV Pulmonary emboli Dx post partum cardiomyopathy with pulmonary emboli CT 28F post partum dyspnea

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Arteries


28 year old post partum female complaining of recent SOB

 
 

2. Findings and Diagnosis


28 year old post partum female complaining of recent SOB

CT – Post Partum Cardiomyopathy with Pulmonary Emboli to Right Lower Lobe
35-year-old female with an 8-year history of post- partum cardiomyopathy presents with a history of chest pain. CT of the chest with contrast in an axial projection, at the level of the heart, shows an enlarged left ventricle. The right lower lobe segmental arteries show filling defects and absence of contrast (maroon circle in b), compared to the left lower lobe arteries (white circle b). An external defibrillator is present.
Ashley Davidoff MD TheCommonVein.net 253Lu 136165cL
  • Clinical Context

    Feature Details
    Age/Sex 28-year-old female
    Clinical Setting Postpartum period
    Presenting Symptom Acute dyspnea
    Relevant History Recent delivery, no prior cardiac disease
    Modality CT Chest with contrast (CTPA protocol)

    Radiologic Findings

    Region Finding
    Heart Dilated left ventricle (LV)
    Pulmonary Arteries Bilateral segmental filling defects (consistent with PE)
    Lungs Mild vascular congestion
    Mediastinum Enlarged cardiac silhouette
    Pleura Trace bilateral effusions (incidental)

    Explanation of Radiologic Terms

    Term Definition
    Dilated LV Enlargement of the left ventricular chamber, usually due to reduced contractility or volume overload
    Filling defect (PA) Hypodense region in a contrast-opacified vessel, representing embolic obstruction
    Cardiomegaly Enlargement of the cardiac silhouette; often a surrogate for volume overload or cardiomyopathy

    Radiologic Analysis

    Element Interpretation
    Parts (Units) Heart chambers (LV, LA), pulmonary arteries, pulmonary veins
    Size Enlarged left ventricle and overall cardiomegaly
    Shape Globular cardiac contour; central filling defects in pulmonary arteries
    Position Central mediastinal structures with segmental emboli bilaterally
    Character Non-enhancing filling defects (PE); soft tissue cardiac density, no calcification
    Time Acute onset in postpartum period; CT findings suggest subacute PE and evolving cardiomyopathy
    Connections and Clinical Associations Postpartum state → hypercoagulability (PE), hemodynamic stress → cardiomyopathy

    Diagnosis

    Type Condition
    Primary Postpartum (Peripartum) Cardiomyopathy
    Concurrent Pulmonary Embolism

    Differential Diagnosis

    Most Likely Diagnoses

    Disease Category Specific Diagnosis
    Circulatory Postpartum cardiomyopathy
    Circulatory Pulmonary embolism (segmental)

    Other Less Likely Considerations

    Disease Category Specific Diagnosis
    Infection Postpartum myocarditis
    Mechanical Amniotic fluid embolism
    Metabolic Hyperthyroid cardiomyopathy
    Neoplastic Choriocarcinoma with embolic spread

    Key Points & Pearls

    • In postpartum patients with dyspnea, always evaluate for both cardiac and vascular causes.

    • CT allows simultaneous evaluation of cardiac chamber size and pulmonary vasculature.

    • Postpartum cardiomyopathy is a diagnosis of exclusion and often presents with LV dilation and heart failure.

    • Pulmonary embolism should be high on the differential in any postpartum patient with acute respiratory symptoms.

    • The combination of LV dilation and segmental PEs is unusual and strongly suggests dual pathology.

3. Clinical


CT – Post Partum Cardiomyopathy with Pulmonary Emboli to Right Lower Lobe
35-year-old female with an 8-year history of post- partum cardiomyopathy presents with a history of chest pain. CT of the chest with contrast in an axial projection, at the level of the heart, shows an enlarged left ventricle. The right lower lobe segmental arteries show filling defects and absence of contrast (maroon circle in b), compared to the left lower lobe arteries (white circle b). An external defibrillator is present.
Ashley Davidoff MD TheCommonVein.net 253Lu 136165cL

Page 3 – Info


Table 1: Clinical Definition and Context

Feature Description
What is it? A condition of systolic heart failure due to dilated cardiomyopathy arising late in pregnancy or in the early postpartum period. In this case, it coexists with pulmonary embolism, a common complication of the hypercoagulable postpartum state.
Caused by Unknown exact etiology; proposed mechanisms include myocardial inflammation, autoimmune responses, hemodynamic stress, and hormonal shifts. PE is caused by venous thromboembolism, often originating from the lower extremities.
Resulting in Reduced left ventricular contractility, dilation, and low cardiac output. PE leads to vascular obstruction of pulmonary arteries and impaired gas exchange.
Structural Changes Enlarged left ventricle, possible left atrial enlargement; in PE, filling defects in pulmonary arteries and possible right heart strain.
Functional Changes Global systolic dysfunction, dyspnea, hypotension, fatigue; PE may cause hypoxia, tachycardia, pleuritic chest pain.
Diagnosis  
Clinical Dyspnea, orthopnea, edema (cardiomyopathy); pleuritic pain, hemoptysis, tachypnea (PE)
Imaging CT: Dilated LV; CTPA: Pulmonary emboli; Echocardiography: EF ↓
Lab Elevated BNP, troponin (variable), D-dimer (elevated in PE)
Other ECG: Sinus tachycardia; Echo: LV dilation and low EF; LE Doppler for DVT
Complications Heart failure, cardiogenic shock, arrhythmias, recurrent thromboembolism, sudden cardiac death
Treatment Supportive: diuretics, beta blockers, ACE inhibitors (if stable); anticoagulation for PE; mechanical support or transplant if refractory

Table 2: Imaging Patterns and Radiologic Features

Imaging Modality Findings
CT (Cardiac/Angio) Dilated LV, filling defects in pulmonary arteries (PE), cardiomegaly
Echocardiography Dilated LV, ↓ EF, sometimes mitral regurgitation
MRI (Cardiac) Can show myocardial fibrosis or inflammation if myocarditis suspected
CXR Enlarged cardiac silhouette, pulmonary edema (if decompensated)

Key Points & Pearls

  • Postpartum cardiomyopathy is a rare but life-threatening condition, often under-recognized in young women with dyspnea.

  • Coexistence with pulmonary embolism reflects the dual burden of postpartum physiology: volume overload and hypercoagulability.

  • Early diagnosis with CT or echocardiography is essential to guide timely treatment.

  • Consider multidisciplinary care in postpartum patients presenting with combined cardiac and respiratory symptoms.

  • Full recovery of cardiac function can occur with treatment, but some patients may progress to chronic cardiomyopathy or require advanced heart failure therapies.

4. Historical and Cultural


CT – Post Partum Cardiomyopathy with Pulmonary Emboli to Right Lower Lobe
35-year-old female with an 8-year history of post- partum cardiomyopathy presents with a history of chest pain. CT of the chest with contrast in an axial projection, at the level of the heart, shows an enlarged left ventricle. The right lower lobe segmental arteries show filling defects and absence of contrast (maroon circle in b), compared to the left lower lobe arteries (white circle b). An external defibrillator is present.
Ashley Davidoff MD TheCommonVein.net 253Lu 136165cL

Page 4 – Other: Historical and Cultural Reflections

1. Historical Understanding of Postpartum Heart Failure

Period Reference Reflection
19th Century Virchow and Rokitansky Though the term “peripartum cardiomyopathy” was not used, early pathologists noted cases of sudden cardiac failure in postpartum women, attributing it variably to “exhaustion” or “puerperal fever” without understanding the cardiac cause.
20th Century (1937) Demakis et al., American Heart Journal First systematic description of peripartum cardiomyopathy as a distinct clinical entity characterized by heart failure in the absence of other causes, appearing late in pregnancy or early postpartum.

2. Literary Allusion: The Heart Under Strain

Work Author Relevance
“To My Dear and Loving Husband” Anne Bradstreet (17th-century Puritan poet) Bradstreet, a mother of eight, wrote about the emotional and physical intensity of motherhood. Her poetry—though not medical—evokes the burdens and vulnerabilities borne by women postpartum, metaphorically paralleling the physiologic demands placed on the heart.

3. Artistic Representation: The Maternal Body and Vulnerability

Artist Work Relevance
Käthe Kollwitz Woman with Dead Child (1903) A powerful etching reflecting maternal loss and fragility. While not specifically about cardiomyopathy, the image underscores the postpartum body’s vulnerability, evoking the silent struggles many women faced—sometimes unknowingly—from undiagnosed conditions like peripartum cardiomyopathy.

4. Etymology and Medical Terminology

Term Origin Meaning
Peripartum Latin peri- (around) + partum (childbirth) Refers to the period immediately before and after childbirth
Cardiomyopathy Greek kardia (heart) + myo (muscle) + pathy (disease) Denotes a disease of the heart muscle, often with weakened contractility

Key Points & Pearls

  • The medical recognition of postpartum cardiomyopathy is relatively recent, with early descriptions scattered and often misunderstood.

  • Cultural portrayals of maternal fragility, like those of Kollwitz or Bradstreet, can illuminate the invisible tolls of childbirth—now partially understood through diagnoses like PPCM.

  • Art and literature help bridge the emotional and physiological realities of motherhood, enriching the clinical appreciation of postpartum disorders.

  • The etymology of the term “cardiomyopathy” reinforces its focus on intrinsic muscle disease—distinct from ischemic or valvular pathology.

5. MCQs


 

Page 5 – MCQs

Question 1

Which imaging finding is most consistent with postpartum cardiomyopathy?

A. Normal left ventricular size with apical thrombus
B. Dilated left ventricle with reduced ejection fraction
C. Concentric left ventricular hypertrophy with pericardial effusion
D. Right ventricular dilation with preserved LV function

Option Correct? Explanation
A Apical thrombus is possible but not specific; LV should be dilated
B Classic finding of postpartum cardiomyopathy is LV dilation with systolic dysfunction
C Hypertrophy and effusion are not typical of PPCM
D Suggests pulmonary hypertension or PE predominance, not PPCM

Question 2

What is the most likely mechanism for pulmonary embolism in the postpartum period?

A. Sepsis-induced vasculitis
B. Amniotic fluid embolism
C. Venous thromboembolism from lower extremity DVT
D. Vasculitis of the pulmonary arteries

Option Correct? Explanation
A Sepsis may cause DIC but not PE in this setting
B Amniotic fluid embolism is a separate entity—non-thrombotic and catastrophic
C The postpartum state is hypercoagulable, leading to DVT and PE
D Rare and unrelated to typical postpartum physiology

Question 3

Which of the following clinical features would best distinguish postpartum cardiomyopathy from pulmonary embolism?

A. Elevated BNP
B. Acute dyspnea
C. LV systolic dysfunction on echocardiography
D. Sinus tachycardia on ECG

Option Correct? Explanation
A BNP may be elevated in both conditions
B Dyspnea occurs in both
C LV dysfunction on echo points to cardiomyopathy rather than PE
D Non-specific finding seen in both disorders

Question 4

What imaging modality is most appropriate for initial confirmation of pulmonary embolism in this patient?

A. Non-contrast CT
B. Chest X-ray
C. CT Pulmonary Angiography (CTPA)
D. Echocardiogram

Option Correct? Explanation
A Cannot visualize emboli without contrast
B May show indirect signs but not diagnostic
C CTPA is the gold standard for detecting PE
D Echo may show RV strain but does not confirm PE directly

Question 5

Which of the following is not a typical complication of postpartum cardiomyopathy?

A. Heart failure
B. Arrhythmia
C. Coronary artery aneurysm
D. Thromboembolism

Option Correct? Explanation
A Common complication of LV dysfunction
B Arrhythmias (VT/VF) are known risks
C Coronary aneurysm is not associated with PPCM
D LV dysfunction increases risk for intracardiac thrombus and embolism

Question 6

Which of the following best explains the co-occurrence of both PE and cardiomyopathy in the postpartum period?

A. Coronary vasospasm
B. Hypercoagulability and hemodynamic stress
C. Iatrogenic fluid overload during labor
D. Autoimmune thyroiditis

Option Correct? Explanation
A Not related to either pathology directly
B Dual pathology: coagulation changes → PE; volume/hormonal stress → cardiomyopathy
C Fluid overload may worsen heart failure, but doesn’t cause PE
D Can cause metabolic cardiomyopathy but unrelated to PE

Question 7

What treatment is most urgently indicated upon diagnosis of pulmonary embolism in a postpartum woman?

A. ACE inhibitors
B. Intravenous diuretics
C. Anticoagulation
D. Intra-aortic balloon pump (IABP)

Option Correct? Explanation
A Used in cardiomyopathy, but not urgently in PE
B Treats fluid overload, not the embolism
C Anticoagulation is the cornerstone of PE management
D Used only in refractory cardiogenic shock, not first-line for PE

 

 

6. Memory Image


Post Partum Cardiomyopathy
Ashley Davidoff TheCommonVein (139965.heart AI)

Pregnancy-associated Hypercoagulability – Virchows Triad 

Virchow’s Triad This diagram shows the triad of factors proposed by Virchow, that each or in combination can result in venous or arterial thrombosis. In this case venous thrombosis is shown with a normal vein and its valves shown to the left and thrombosis in a distended vein (light maroon) is shown to the right of the image. code vein artery thrombus embolus hypercoagulability endothelial injury hemostasis Virchow’s triad Davidoff art copyright 2024 all rights reserved 10357 m W.33k.8sDatabase ID: 124221


🔎 Summary of Key Updates

Definition refined → PPCM is a dilated cardiomyopathy with LV dysfunction postpartum
ImagingECHO first, MRI for further evaluation, CXR adjunct
Labs → BNP, troponins, anemia, thyroid function
Treatment updatedHF meds + thromboembolism prevention if EF < 35%
Prognosis added50% recovery, 40% chronic HF, 10% severe cases

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