Scenario in a Nutshell
Peripartum cardiomyopathy complicated by cardiogenic shock.
Stage 1: Initial assessment of new onset shortness of breath in the early postpartum period.
Stage 2: Acute pulmonary oedema and impending cardiogenic shock.
Stage 3: Management of cardiogenic shock.
Target Learner Groups
All members of the multidisciplinary obstetric team: postnatal ward midwifery staff, obstetricians, anaesthetists, cardiologists.
| Specific learning opportunities |
|---|
| Knowledge of differential diagnosis of postpartum breathlessness |
| Knowledge of clinical presentation of peripartum cardiomyopathy |
| Demonstrate appropriate assessment and management of heart failure presenting in the early postpartum period |
| Suggested learners (to represent their normal roles) | In the room from the start | Available when requested |
|---|---|---|
| Anaesthetic ST3+ | √ | |
| Obstetric ST1/ ST3+ | √ | |
| Midwife Coordinator | √ | |
| Midwife | √ | |
| Operating Department Practitioner (ODP)/anaesthetic nurse | √ | |
| Cardiology ST6+ | √ | |
| Suggested facilitators | ||
| Faculty to play the role of junior midwife on postnatal ward handing over | √ |
Details for Facilitators
Patient Demographics
Name: Marian Age: 35 Gestation: Postnatal Booking weight: 95 kg Parity: Now P1 |
Scenario Summary for Facilitators
A 35-year-old (now para 1) develops symptoms of breathlessness on the second day following an elective caesarean section delivery for breech. She suffers with mild asthma, using a salbutamol inhaler PRN.
Initially she has signs of mild heart failure, but despite initial heart failure therapy, rapidly deteriorates to develop cardiogenic shock with severe pulmonary oedema requiring transfer to cardiac intensive care.
The patient has peripartum cardiomyopathy complicated by cardiogenic shock.
Set-up Overview for Facilitators
| Clinical setting | On postnatal ward |
| Patient position | Semi-recumbent on postnatal bed |
| Initial monitoring in place | Nil monitoring |
| Other equipment | All usual equipment on postnatal ward is available |
| Useful manikin functions | Abnormal breath sounds (pulmonary oedema)Audible heart sounds (third heart sound)Intubation |
Medical Equipment
For core equipment checklist, see Chapter 9.
| Additional equipment specific to scenario | ||
|---|---|---|
| Arterial line | Resuscitation trolley | Continuous positive airway pressure machine |
| Drugs: | ||
| Furosemide | Noradrenaline | Antibiotics |
| GTN | Dobutamine | Dalteparin |
| Hydralazine | Adrenaline | |
| Levosimendan | ||
Information Given to the Learners
SBAR handover from faculty (playing the role of junior midwife on postnatal ward) to obstetric trainee and anaesthetic trainee
|
Scenario Schedule
Suggested Topics for Debrief Discussion
What differential diagnosis were you thinking about when you first assessed the patient?
Would this be easy to manage on your unit?
Discussion
Peripartum cardiomyopathy (PPCM) typically presents during the first week postpartum with dyspnoea; however, subtle preceding symptoms such as fatigue, cough, oedema and abdominal discomfort may have been mistakenly attributed to normal symptoms of pregnancy leading to delayed diagnosis. PPCM is a diagnosis of exclusion, defined as ‘an idiopathic cardiomyopathy presenting with heart failure (HF) secondary to left ventricular systolic dysfunction (LVEF < 45%) towards the end of pregnancy or in the months following delivery, where no other cause is found’ (Sliwa et al., 2014). Symptom onset may be gradual or sudden and clinical presentation may overlap with several other important diagnoses, thus emphasising the need for prompt assessment and diagnosis (Table 31.1). Once a diagnosis of acute HF has been established, careful assessment of the blood pressure, heart rate, respiratory rate, oxygen saturation and tissue/organ perfusion should be performed to determine the patient’s haemodynamic and respiratory status as this will determine management strategy (Figure 31.1).
Table 31.1 Cardiac causes of breathlessness during pregnancy.
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