What is the diagnosis for a postpartum woman with proteinuria, edema, and pericardial effusion?

From the Guidelines

The combination of postpartum proteinuria, edema, and pericardial effusion suggests postpartum preeclampsia or a related condition like peripartum cardiomyopathy, and the patient should be hospitalized for evaluation and treatment with antihypertensive medications, magnesium sulfate, and diuretics as needed, with close monitoring of cardiac function and blood pressure. The patient's symptoms require immediate medical attention to prevent potential complications such as seizures, stroke, or heart failure.

Evaluation and Treatment

• Hospitalization for evaluation with blood pressure monitoring, laboratory tests (complete blood count, liver and kidney function, urine protein), and echocardiography to assess cardiac function 1
• Antihypertensive medications like labetalol (starting at 200-400 mg orally twice daily) or nifedipine (10-20 mg orally every 4-6 hours) to maintain blood pressure below 150/100 mmHg 1
• Magnesium sulfate (4-6g IV loading dose followed by 1-2g/hour infusion for 24 hours) may be needed to prevent seizures if severe preeclampsia is diagnosed 1
• Diuretics like furosemide (20-40 mg IV or orally) may help manage edema and pericardial effusion 1
• Consideration of bromocriptine for acute peripartum cardiomyopathy treatment, particularly in women with LVEF <25% or cardiogenic shock, although the efficacy and safety remain uncertain at this time 1

Pathophysiology and Monitoring

• The underlying pathophysiology involves endothelial dysfunction, inflammatory activation, and fluid retention that can persist or develop newly after delivery, affecting multiple organ systems including the cardiovascular system, kidneys, and peripheral tissues
• Close monitoring is essential as these conditions can rapidly deteriorate, potentially causing seizures, stroke, or heart failure
• Multidisciplinary management with obstetrics, maternal-fetal medicine, neonatology, and pediatrics teams, especially for multidisciplinary recommendations regarding lactation and contraceptive planning 1

From the Research

Postpartum Proteinuria, Edema, and Pericardial Effusion

• Postpartum proteinuria can be a sign of underlying renal disease, as seen in a study where 71% of patients with persistent proteinuria after preeclampsia were diagnosed with underlying renal disease 2.
• Edema is a common symptom of postpartum toxemia, also known as eclampsia, which is characterized by hypertension, edema, and proteinuria 3.
• Pericardial effusion can be a complication of peripartum cardiomyopathy, a rare form of heart failure that affects women late in pregnancy and the postpartum period 4, 5.

Causes and Risk Factors

• Hypertensive disorders of pregnancy, such as preeclampsia, can increase the risk of postpartum proteinuria and peripartum cardiomyopathy 6, 4.
• Black race and maternal age older than 30 years are also risk factors for peripartum cardiomyopathy 4.
• The exact pathogenesis of peripartum cardiomyopathy remains unknown, but theories include genetic predisposition, myocardial inflammation, and angiogenic dysregulation 5.

Diagnosis and Management

• Diagnosis of peripartum cardiomyopathy requires a high index of suspicion and can be difficult due to the normal physiologic changes of pregnancy 4.
• Echocardiography showing decreased myocardial function is at the center of the diagnosis of peripartum cardiomyopathy 5.
• Management of peripartum cardiomyopathy relies on the general guidelines of management of other forms of non-ischemic cardiomyopathy, with special attention to fetal safety when choosing medications 5.
• Persistent proteinuria after preeclampsia should be evaluated with respect to underlying renal disease, and a percutaneous renal biopsy should be performed in patients with positive signs of underlying renal disease 2.