Surviving Severe Peripartum Cardiomyopathy without Blood Transfusion: A Multidisciplinary Case Report from South-Eastern Nigeria

Abstract

Peripartum cardiomyopathy (PPCM) is an uncommon but potentially fatal cause of heart failure in late pregnancy or the puerperium, with more complex management in resource-limited settings and in patients who decline blood transfusion. A 35-year-old unbooked primigravida at 37 weeks, Jehovah’s Witness, presented with New York Heart Association (NYHA) Class IV heart failure: dyspnoea at rest, orthopnoea, productive cough and bilateral leg swelling. O ₂ saturation was 86%–88% on room air, and haematocrit was 21%. Echocardiography confirmed PPCM with dilated left ventricle, left ventricular ejection fraction (LVEF) 30%, mild functional mitral regurgitation and mildly impaired right ventricular (RV) function (tricuspid annular plane systolic excursion: 14 mm). After intensive care unit stabilisation with vasopressors, diuretics and oxygen, labour was induced under epidural analgesia to reduce sympathetic stress. She delivered vaginally a live neonate with good Apgar scores. Postpartum, she required intermittent continuous positive airway pressure and haemodynamic support. Owing to refusal of transfusion, blood conservation was achieved with erythropoietin, iron dextran and haematinics. At 6 months, LVEF > 50%, RV function normalised and she improved to NYHA Class I–II. Structured multidisciplinary care, neuraxial analgesia, non-invasive ventilation and patient blood management strategies can achieve favourable outcomes in severe PPCM complicated by significant anaemia and transfusion refusal, even in resource-limited settings.