Takotsubo cardiomyopathy--transient left ventricular apical ballooning mimicking acute myocardial infarction.

Takotsubo cardiomyopathy is characterized by transient left ventricular dysfunction with clinical symptoms of chest pain, electrocardiographic changes of ST-segment elevation or T wave inversion, which mimics acute myocardial infarction in patients without angiographically significant coronary artery stenosis. We report a 75-year-old woman with a history of chest tightness who presented with typical pictures of takotsubo cardiomyopathy. Acute myocardial infarction was initially diagnosed based on the electrocardiographic changes and elevated troponin. Apical akinesis and ballooning with basal hyperkinesis were noted during left ventriculography. Coronary angiography, however, did not show significant coronary artery stenosis. Electrocardiography was normal 3 months later. Follow-up echocardiography did not show any wall motion abnormality. This patient remained well without chest pain or dyspnea over 24 months of follow-up. Optimal medical management of takotsubo cardiomyopathy remains unclear. This patient received diltiazem to prevent possible coronary artery spasm. The prognosis of this syndrome seems to be favorable except for occasional mortality due to left ventricular rupture or ventricular arrhythmia. Recurrence of this syndrome is rare.     

Pneumomediastinum as a cause of acute chest pain postpartum.

Pneumomediastinum can easily be mistaken for a pulmonary embolus or myocardial infarction. We describe herein a case of pneumomediastinum postpartum. A primigravida complained five-hours postpartum of acute chest pain and mild dyspnea. The initial (working) diagnosis was pulmonary embolus and the patient was treated with antithrombotic therapy. A CT scan revealed the real cause of the chest pain: pneumomediastinum. The patient was given adequate analgesia and two days later was able to leave the hospital in good clinical condition. We suggest that in the case of acute chest pain during or shortly following labor, pneumomediastinum should be considered.     

Postpartum Depression and Apical Ballooning Syndrome (Takotsubo Syndrome)

BackgroundAcute cardiac complications occur occasionally during pregnancy and in the immediate postpartum period. Some of these cardiac scenarios are rare and provide a diagnostic challenge. We report a case of apical ballooning syndrome (ABS), also known as takotsubo cardiomyopathy or broken-heart syndrome, in a postpartum patient.CaseA 32-year-old multigravid woman presented at 17 days after delivery with chest pain typical for cardiac ischemic pain. Her prior obstetrical history included two uncomplicated vaginal deliveries, and the current postpartum period had been uncomplicated until the time of presentation. Cardiac catheterization was performed and showed normal coronary blood vessels with no evidence of coronary artery occlusion. Left ventricular systolic function was moderately depressed, with an ejection fraction of 45%. The patient had full recovery of myocardial function in less than 40 days, with a subsequent echocardiogram during that time showing a normal ejection fraction of 65%.ConclusionApical ballooning syndrome is a rare reversible cardiac condition that should be differentiated from ischemic and peripartum cardiomyopathy, especially in the immediate postpartum period.     

Mothers’ Reports of Postpartum Pain Associated with Vaginal and Cesarean Deliveries: Results of a National Survey

ABSTRACT: Background: As cesarean rates increase worldwide, a debate has arisen over the relationship of method of delivery to maternal postpartum physical health. This study examines mothers’ reports of their postpartum experiences with pain stratified by method of delivery. Methods: Listening to Mothers II was a survey of a total of 1,573 (200 telephone and 1,373 online) mothers aged 18 to 45 years, who had a singleton, hospital birth in 2005. They were interviewed by the survey research firm, Harris Interactive, in early 2006. Online respondents were drawn from an existing Harris panel. Telephone respondents were identified through a national telephone listing of new mothers. Results were weighted to reflect a United States national birthing population. Mothers were asked if they experienced any of eight postpartum conditions and the extent and the duration of the problem. Responses were compared by method of delivery. Results: The most frequently cited postpartum difficulty was among mothers with a cesarean section, 79 percent of whom reported experiencing pain at the incision in the first 2 months after birth, with 33 percent describing it as a major problem and 18 percent reporting persistence of the pain into the sixth month postpartum. Mothers with planned cesareans without labor were as likely as those with cesareans with labor to report problems with postpartum pain. Almost half (48%) of mothers with vaginal births (68% among those with instrumental delivery, 63% with episiotomy, 43% spontaneous vaginal birth with no episiotomy) reported experiencing a painful perineum, with 2 percent reporting the pain persisting for at least 6 months. Conclusions: Substantial proportions of mothers reported problems with postpartum pain. Women experiencing a cesarean section or an assisted vaginal delivery were most likely to report that the pain persisted for an extended period. (BIRTH 35:1 March 2008)     

Myocardial infarction in early pregnancy

Acute myocardial infarction (AMI) during pregnancy is usually transmural and occurs in late pregnancy with a peak incidence during the peripartum or postpartum periods. We report a pregnancy-related AMI, which occurring as early as the first trimester, was treated conservatively with antithrombotic and anti-ischemic drugs both acutely and through the rest of the ultimately successful pregnancy.     

Recurrent giant cell tumor of the thoracic spine with bilateral pulmonary metastases.

Giant cell tumor (GCT) of bone is a challenging clinicopathologic entity. Despite its benign designation, it has the capacity to recur locally and develop rare pulmonary metastasis. We report a case of histologically proven recurrent GCT of the spine (T7-8) involving spinal cord compression, direct extension to 1 lung, and bilateral pulmonary metastases. A 30-year-old woman presented with back pain, and underwent anterior reconstruction for GCT of the T7 at another hospital. As her symptoms deteriorated, she underwent laminectomy at the same hospital 2 months after the first surgery. One year after the first surgery, she was referred to our hospital on account of a progressive neurological deficit and intractable back pain, and underwent an anterior tumor resection at T7-8 and reconstruction, due to tumor recurrence. Postoperatively, the patient did not show neurologic improvement, but her pain decreased. The patient displayed no respiratory difficulties and no apparent change in follow-up chest radiographs for more than 2 years since surgery. This is the first reported case of bilateral pulmonary metastases from GCT of the thoracic spine.     

Maternal death from postpartum necrotizing fasciitis arising in an episiotomy: a case report

Background: Necrotizing fasciitis is a rare condition. We report a fatal case arising from an episiotomy in a previously healthy woman.Case: A healthy 23-year-old prima gravida white female underwent vaginal delivery with repair of a proctoepisiotomy. Eighty-four hours postpartum, she developed increasing perineal swelling with severe pain. She presented on the 4th postpartum day with edema, erythema localized to the perineum, and vital signs significant only for tachycardia of 120/min. With a leukocytosis of 45,000/mul (87%) neutrophils, she was admitted to the hospital with an initial diagnosis of perineal cellulitis and empirically started on broad-spectrum intravenous antibiotic therapy. The patient's condition continued to deteriorate and she was then transferred to our facility on postpartum day 9 where a team performed two radical debridements of all necrotic tissue. Despite this and a broadened antibiotic coverage, the patient eventually experienced cardiopulmonary arrest and died on postpartum day 12.Conclusion: Necrotizing fasciitis must be considered in the differential diagnosis of the postpartum patient presenting with severe vulvar pain and erythema. Our patient exemplifies the obscure presentation with seemingly minimal skin changes. Any delay in diagnosis and treatment, which must include expeditious aggressive surgical debridement, will likely result in severe morbidity or mortality.     

Acute coronary syndrome associated with oral administration of ritodrine hydrochloride during pregnancy: a case report.

We report a case of acute coronary syndrome associated with the oral administration of ritodrine hydrochloride. Ten days following the administration of ritodrine hydrochloride, the patient complained of chest pain, and an electrocardiogram showed ST elevation and ST depression. Intensive care was initiated. She recovered without chest pain.     

Trombosis séptica puerperal de la vena ovárica

We report a case of postpartum ovarian vein thrombosis and review the literature on the topic. The patient developed fever and abdominal pain after delivery. Empiric antibiotic treatment was prescribed and computed tomography showed right ovarian vein thrombosis.Ovarian vein thrombosis is an exceptional cause of postpartum fever. Differential diagnosis must be made with more frequent complications (appendicitis, pyelonephritis, and tubo-ovarian abscesses). The pathogenesis is multifactorial and treatment is based on a combination of antibiotics and anticoagulation. The diagnostic procedure of choice is computed tomography scan.     

Neurological complication after hip-flexed posture during labour with epidural analgesia

Obstetrical positioning is used more and more often because of the supposed or proven benefits although side effects are not well known. We therefore report the case of a patient who presented with a postpartum neurological deficit after a seven hour hip-flexed posture during labour under epidural analgesia. The parturient did not complain of pain or discomfort during labour. The neurological injury was suspected because of delayed recovery of epidural analgesia induced-motor block. Neurological examination disclosed sensory and motor abnormalities in the left femoral and sciatic nerve distribution areas. The early performed lumbar CT scan did not show any complication and electromyographic evaluation performed on the ninth postpartum day was normal. Three months after delivery, some degree of neuropathic pain in the sciatic nerve distribution remained. The risk of neurological injury directly related to obstetrical positioning is discussed. Prolonged positioning using a posture which can induce nerve stretching should be avoided. This is especially true when the patient is receiving epidural analgesia which can mask pain or discomfort.     

Pyometria after hemostatic square suture technique

BACKGROUND: The square suture technique to achieve hemostasis for postpartum hemorrhage has been described in the medical literature. In a prior report of 23 cases, there were no complications from the technique. CASE: A young woman with an gravida 1 para 0 with an uncomplicated prenatal course presented at 40 weeks' estimated gestational age in active labor. Cesarean delivery was performed for arrest of dilatation and was complicated by postpartum hemorrhage unresponsive to medical therapy and uterine artery ligation. Several hemostatic square sutures were placed, obtaining hemostasis. The patient presented 4 weeks postpartum with pain and mucopurulent discharge. Pyometrium was discovered at the time of dilation and curettage. CONCLUSION: Pyometrium may result from the use of hemostatic square suture technique for control of postpartum hemorrhage.     

A study on the pre-admission characteristics of patients with acute myocardial infarction.

To clarify an appropriate policy to implement Emergency Medical Services (EMS) in Taiwan based on the profiles of patients with acute myocardial infarction (AMI), and to compare the differences of clinical features accompanied by AMI between Orientals and Westerners, 63 consecutive patients with definite AMI entering the emergency room (ER) from September 1989 through January 1990 were studied. Several interesting facts were found: 1) 9.5% (6/63) of patients took public ambulance to seek medical help; 2) 89% came from out of our jurisdiction, and 62% (39/63) were referred from general practitioners or the ER of community hospitals; 3) There were 5 truly delayed cases (7.9%) owing to a lack of sense of danger in case of chest pain; 4) 50% of our cases occurred during sleeping; 5) The time of onset peaked from 0 AM to 6 AM; 6) While 63.5% of patients visited ER within 6 hours after the onset of acute symptoms, only 12.7% were treated with thrombolytic therapy; and 7) AMI patients stayed in ER for an average of over 4 hours. With limited cases, although trends were evident, firm conclusions were not warranted. The following crucial recommendations are suggested: 1) EMS system in terms of caring of AMI patients still needs a well-designed study to map out an appropriate policy; 2) The strengthening education to physicians working in ER or to all primary care physicians of an early use of thrombolytic agents in indicated cases should be warranted to offer timely therapy when necessary; 3) General public should be educated to call for medical help as soon as possible in case of chest pain.     

A case of uterine rupture discovered in the postpartum period

Because of the increasing number of cicatricial uteruses, uterine ruptures are likely to become more frequent. However, few cases discovered in the postpartum period are described in literature. Our case report describes a uterine rupture, which occurred during a quick vaginal delivery, in a patient with previous cesarian section. The diagnosis has been made few days after delivery, the patient presenting pelvic pain and fever. We do not disagree with the principle to check uterine scar only when suspicion of rupture, but we should keep in mind that in case of endometritis in the postpartum period, with cicatricial uterus, it would be necessary to research uterine rupture by fitted imaging.     

Apical hypertrophic cardiomyopathy: clinical, echocardiographic and angiographic features in 3 Chinese patients

We present 3 cases of apical hypertrophic cardiomyopathy. The presenting symptoms were dyspnea on exertion in 2 of 3 patients, typical anginal pain in 1 patient, atypical chest pain in 1 patient, and fatigue in 1 patient. One patient was asymptomatic with an abnormal electrocardiogram. Sustained apical impulse was noted in all patients, Grade 1/6 systolic murmur was audible in 2 patients. Electrocardiogram showed T wave inversion in the left precordial leads in all patients with amplitudes of 1.4, 0.8 and 2.0 mV, respectively. Isolated apical hypertrophy was noted in all patients. Two-dimensional echocardiogram and the left ventriculogram revealed a "spade-shaped" configuration of the left ventricular cavity at endo-diastole in only one patient. Left ventricular end diastolic pressures were elevated and coronary angiograms were normal in all 3 cases. We conclude that this disease entity should be considered in patients whose electrocardiogram shows a large inverted T wave in the left precordial leads, either accompanied by symptoms such as dyspnea on exertion or chest pain, or even when asymptomatic. Echocardiogram is the most useful screening tool in the diagnosis of apical hypertrophic cardiomyopathy.     

Puerperal diastasis of the pubic symphysis. A case report

BACKGROUND: Puerperal diastasis of the symphysis pubis is an uncommon intrapartum complication. Patients often respond to conservative measures. A small percentage of patients will develop chronic pain and require surgical treatment, which involves debridement or fusion of the symphysis pubis. CASE: A 33-year-old woman, gravida 1, para 0, with an uncomplicated prenatal course developed acute-onset anterior pubic pain during an otherwise normal delivery. This anterior pubic pain radiated to the left buttock and thigh. The pain persisted postpartum and was exacerbated by any movement. Radiographs confirmed pubic symphysis diastasis. The patient responded to conservative management and was essentially pain free by 10 weeks postpartum. CONCLUSION: The diagnosis should be considered in a patient with an acute onset of pain during delivery that does not improve postpartum.     

Postpartum periarticular hip abscess with later coxitis caused by group B streptococcus.

Intrapartum haematogenous spread of vaginal group B Streptococcus is rare, but it can lead to severe complications like abscesses, endocarditis and meningitis postpartum. We report a postpartum periarticular hip abscess caused by group B Streptococcus. Clinically it caused pain in the hip and a compression of the femoral nerve with motor and sensory component. Diagnosis was made by aspiration under computed tomography control. The only sign of infection was an increased sedimentation rate. After antibiotic treatment the symptoms disappeared and the abscess vanished, but it was reactivated 4 months after delivery, leading to arthritis of the hip joint. Another antibiotic treatment was administered for 8 weeks. 17 months postpartum the patient is well, but a development of a secondary coxarthrosis can not be excluded.     

Langerhans' cell histiocytosis presenting with a para-aortic lesion and heart failure.

Langerhans' cell histiocytosis (LCH) is an uncommon disease with variable manifestations. We report a case of LCH with the unusual initial presentations of chest pain and progressive heart failure in a 5-year-old boy. Chest radiography revealed a wide mediastinum with cardiomegaly. Electrocardiography showed first-degree atrioventricular block and an inverted T wave over V4-V6. Echocardiography, computed tomography, and magnetic resonance imaging of the chest all showed an infiltrating lesion that enveloped the entire heart, great vessels, and coronary arteries. Pathologic examination of the biopsy specimen revealed LCH. Chemotherapy, which included prednisolone, vincristine, methotrexate, and 6-mercaptopurine, had only a minimal effect on the tumor. After the addition of etoposide, the lesion decreased in size, and the symptoms and signs of heart failure and chest pain were ameliorated.     

Pregnancy in a woman with partial absence of the left pericardium. A case report

Absence of the left pericardium is a rare congenital anomaly, occasionally associated with chest pain syndromes. There have been six cases of death due to strangulation of the left atrial appendage in patients with this condition. We present the first report of a patient with this anomaly who was followed through pregnancy.     

Marked hypocalcemia after tocolytic magnesium sulphate therapy

Symptomatic hypocalcemia has been reported infrequently in association with magnesium sulfate (MgSO (4)) tocolytic therapy. We report a 38-year-old woman who presented in preterm labor at 24 3/7 weeks. Twenty hours after starting MgSO (4), she developed chest pain. Studies revealed therapeutic serum Mg level, total serum calcium (Ca) = 5.5 mg/dL, 24-hour urine Ca = 763.9 mg, and low serum uric acid and phosphate levels. All studies corrected day 1 postpartum; urine Ca level corrected on day 2. Even short courses of MgSO (4) can result in severe hypocalcemia, raising the question of whether Ca levels should be routinely monitored.