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.)
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.
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.
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.
This is a rare case of constrictive pericarditis secondary to tuberculosis in pregnancy. 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.
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.  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. Dyspnea, fatigue, palpitation and edema are common symptoms of constrictive pericarditis. 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. Beta-adrenergic blockers and digoxin are only used for control of atrial fibrillation.
This case is an example of conservative management of constrictive pericarditis during pregnancy with definitive plan of pericardiectomy after delivery.
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3. Probst R, Mier T. Acute pericarditis complicating pregnancy. Obstet Gynecol 1963;22:393.
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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.
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