DOI: 10.7860/JCDR/2015/10611.

5522
Case Report

Postpartum Acute Pulmonary

Anaesthesia Section

Oedema with Subclinical

Rheumatic Heart Disease
Padmaja R1, sri Krishna Padma challa rao. Gande2

ABSTRACT
Acute dyspnea with pulmonary oedema in postpartum is uncommon but life-threatening event. Contributing factors for pulmonary
oedema include, administration of tocolytics, underlying cardiac disease, iatrogenic fluid overload and preeclampsia acounting 0.08% of
pregnancies. Pulmonary embolism, amniotic fluid embolism, pneumonia, aspiration and pulmonary oedema are some of the potentially
devastating conditions that should be considered by the attending physician.
Here, we report a case of postpartum acute pulmonary oedema referred to causality after an emergency caesarean section in a private
hospital. No matter what the underlying pathology, prompt administration and appropriate resuscitation is always the first priority. Only
after the patient has been stabilized attention must be turned to diagnosis and specific treatment. A diagnosis of severe Mitral Stenosis,
probably of rheumatic origin was made after stabilizing the patient.

Keywords: Mitral stenosis, Pulmonary oedema, Sub clinical carditis

CASE Report Careful review of patient medication chart excluded tocolytic

A 22-year-old patient was referred to Konaseema institute of therapy and iatrogenic fluid overload in our case. Echocardiography
medical sciences at casuality, with severe respiratory distress. She revealed a clinically unexpected finding of mitral valve stenosis.
had undergone an emergency caesarean section under spinal Rheumatic fever is the leading cause of mitral valve stenosis [3-5],
anaesthesia for premature rupture of membranes, 12 h before but our patient had no history of rheumatic fever. Only 50 to 70%
admission in a local hospital. She had marked respiratory distress of patients give a history of rheumatic fever which may be because
so referred to tertiary care hospital, at the time of admission with such patients may have suffered from subclinical rheumatic fever
oxygen saturation of 49% on room air. Her pulse was 170/min not associated with polyarthritis [6]. The absence of a history of
rheumatic fever in a patient does not precludes the presence of
on monitor, low volume on palpation, systolic blood pressure was
rheumatic heart disease correlates with Yazici HU et al., [7].
recorded as 70 mmHg. Clinical examination of lungs showed
bilateral coarse crepitations. Hence she was kept on Synchronized Atrial fibrillation is a common complication of Mitral valve stenosis
Intermittent Mandatory Ventilation(SIMV Mode) mode of mechanical [6] and affects 40% of cases of mitral stenosis [5]. Atrial fibrillation
ventilation and dobutamine and nor adernaline to support circulation. is due to increasing left atrial size and left atrial hypertension [8].
Electrocardiography showed sinus tachycardia and chest X-ray Although our patient had left atrial dilatation (4.8 cm), she had no
showed bilateral infiltrates [Table/Fig-1] by which tentative diagnosis atrial fibrillation.
of pulmonary oedema was made. Our patient was asymptamatic in the entire antenatal period and
To evaluate the cause of pulmonary oedema a review of all the the intraoperative period. The sudden rise in venous return due to
autotransfusion leads to pulmonary oedema in a parturient with
medications she had received and total fluids administered was
significant mitral stenosis which was also seen in our patient [9].
done. History showed that she had regular antenatal check up and
the antenatal history was insignificant. A significant number of patients with suspected rheumatic
carditis have no clinical murmurs [10]. The reported prevalence
She was subjected to echocardiogram which revealed severe
Mitral stenosis with mild mitral regurgitation and severe Pulmonary
artery hypertension (PASP i.e. pulmonary artery systolic pressure
is 67mmHg). History was again reviewed but she had no history of
rheumatic fever or any cardiac symptoms.
She was extubated on day four and discharged on day nine. She
was advised to visit a cardiologist in view of her valvular heart
disease at time of discharge.

DISCUSSION
Significant shortness of breath, tachypnea, rhonchi on auscultation,
evidence of hypoxia by pulse oximetry and arterial blood gas, pink
frothy fluid through endotracheal tube and chest X-ray finding
are consistent with pulmonary oedema. The percentage of
pregnancies that are complicated by acute pulmonary oedema has
been estimated to be 0.08% which is in correlation with previous
studies [1,2].The most common contributing factors include the
administration of tocolytic agents, underlying cardiac disease,
[Table/Fig-1]: The chest X-ray showing bilateral infiltrates
iatrogenic fluid overload and preeclampsia.

Journal of Clinical and Diagnostic Research. 2015 Feb, Vol-9(2): UD01-UD02 1

 Padmaja R et al., Acute Pulmonary Edema in Previously Healthy Pregnant Woman with Sub Clinical Rheumatic Heart Disease: A Case Report www.jcdr.net

of subclinical carditis in rheumatic fever ranges from 0 to 53%. [2] Masuda islam khan, et al. Acute postpartum pulmonary oedema in a 32-year-
old woman five days after caesarean delivery. Journal of Enam Medical College.
Echocardiography is more sensitive and more accurate in
2013;3(2):113-16.
diagnosing valvular involvement in acute rheumatic fever [11,12]. [3] Nordet P. WHO/ISFC. Global programme for the prevention and control of RF/
A recent echocardiographic screening survey from India has also RHD. J In Fed Cardiol. 1993;3:4–5.
suggested a very high prevalence rate (52.4/1000 school children) [4] Eisenberg MJ. Rheumatic heart disease in the developing world: prevalence,
prevention and control. Eur Heart J. 1993;14:122–28.
[13]. One-third of these patients develop chronic valvular heart [5] Conradie C, Schall R, Marx JD. Echocardiographic study of left atrial thrombus in
disease. Occurrence of valvular heart disease in acute rheumatic mitral stenosis. Clin Cardiol. 1995;16:729-31.
fever without evident carditis is observed as study done by Folger [6] Selzer A, Cohn KE. Natural history of mitral stenosis: a review. Circulation. 1972;
45:878–90.
GM et al., [14].
[7] Yazici HU, Akcay B, Ozturk U, Tassal A. A giant left atrium. Türk Kardiyol Dern
We believe that Doppler echocardiography should be done to Ars. 2010;38:223.
suspected pregnant patient to detect subclinical valvular heart [8] Rick AR, Gregory JE. Experimental evidence that lesions with basic charecteristics
of rheumatic carditis can result from anaphylactic hypersensitivity. Bull johns
disease and to prevent untoward complications during perioperative Hopkins hospital. 1993;73:239.
period. Hand-held and mobile forms of echocardiography should [9] Abdul-Majeed Salmasi, Mark Dancy, et al. Unrecognised mitral valve stenosis in
be made available in remote areas of the world. a London multi-ethnic community. Br J Cardiol. 2011;18:138-41.
[10] Tubridy-Clark M, Carapetis JR. Subclinical carditis in rheumatic fever. A
systematic review. Int J Cardiol. 2007;119:54-58.
CONCLUSION [11] Bhaya M, Panwar RB, Beniwal R, Panwar S. Echocardiographic evidence
Mitral stenosis of rheumatic origin is most likely missed and of significant regurgitation can be the sole criterion for diagnosis of probable
underreported because of lack of diagnostic modalities such as rheumatic heart disease. Experience from a large cross-sectional survey. J Am
Coll Cardiol. 2009;53:A409.
echocardiography. Its prevalence is higher than expected and [12] Vijayalakshmi IB, et al. The role of echocardiography in diagnosing carditis in the
provides a challenge to anaesthesiologist, when it is clinically setting of acute rheumatic fever. Cardiol Young. 2005:15-583-88.
unrecognised and present with complications like pulmonary [13] WHO Technical Report, Series. Rheumatic fever and rheumatic heart disease:
Report of a WHO expert panel. Geneva 29 October - 1 November 2001. Geneva:
oedema during perioperative period.
WHO; 2004.
[14] Folger GM, Hajar R, Robida A, Hajar HA. Occurrence of valvular heart disease in
REFERENCES acute rheumatic fever without evident carditis. Colour-flow Doppler identification.
[1] Sciscione Anthony C, Ivester Thomas, Largoza Marissa, Manley James, Br Heart J. 1992;67:434-38.
Shlossman Philip, Colmorgen Garrett HC. Acute Pulmonary Oedema in
pregnancy. Obstetrics and Gynaecology. 2003;101(3):511-15.

PARTICULARS OF CONTRIBUTORS:
1. Assistant Professor, Department of Aanaesthesia, Konaseema institute of Medical Sciences, Amalapuram, Andhra Pradesh, India.
2. Consultant Physician, Deartment of General Medicine, Konaseema Institute of Medical Sciences, Amalapuram, Andhra Pradesh, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Padmaja R,
D. No 65-8-5/1, G P T Road, Mehernagar, Kakinada, EGDT, Andhra Pradesh, India.
E-mai : padmajaanes@gmail.com Date of Submission: Jul 18, 2014
Date of Peer Review: Aug 20, 2014
Financial OR OTHER COMPETING INTERESTS: None. Date of Acceptance: Oct 27, 2014
Date of Publishing: Feb 01, 2015

2 Journal of Clinical and Diagnostic Research. 2015 Feb, Vol-9(2): UD01-UD02