Intraoperative Cardiac Arrest as the First Manifestation of Undiagnosed Peripartum Cardiomyopathy in a Secondary Rural Hospital: A Case Report

Background

Peripartum Cardiomyopathy (PPCM) is an uncommon cause of acute heart failure occurring in late pregnancy or early postpartum. In resource-constrained hospitals without advanced cardiac support or biomarker testing, delayed recognition may lead to catastrophic complications. Case Illustration: A 28-year-old primigravida underwent elective cesarean delivery and developed sudden Pulseless Electrical Activity (PEA) five minutes postpartum. Return of spontaneous circulation was achieved after two cycles of cardiopulmonary resuscitation. Post-arrest evaluation revealed severe global Left Ventricular (LV) systolic dysfunction (Left Ventricular Ejection Fraction [LVEF] 16%) with LV dilation (Left Ventricular Internal Diameter at end-diastole [LVIDd] 5.4 cm) and preserved Right Ventricular (RV) systolic function (Tricuspid Annular Plane Systolic Excursion [TAPSE] 2.2 cm). Emergency echocardiography was performed in the Intensive Care Unit (ICU); therefore, comprehensive hemodynamic data were limited. Inferior vena cava size was within normal limits. Hemoglobin decreased modestly (12.2 to 10.6 g/dL), and no evidence of massive hemorrhage or distributive shock was observed. In the absence of biomarker availability, diagnosis was established based on clinical echocardiographic correlation. The patient required short-term norepinephrine (0.1 mcg/kg/min for 12 hours) and dobutamine (5 mcg/kg/min for 48 hours) with gradual down-titration. Guideline-directed medical therapy was initiated after stabilization, including sacubitril–valsartan, spironolactone, bisoprolol, dapagliflozin, diuretics, and bromocriptine (5 mg twice daily for one week). LVEF improved to 34% at day 10 and recovered to 64% at three months.