Abstract
Background
Hemodynamically significant pericardial effusions during pregnancy are rare but require urgent multidisciplinary intervention to determine necessity and timing of intervention.
Case Summary
A 34-year-old nulliparous woman at 35 weeks and 4 days of gestation presented with acute chest pain and dyspnea. Evaluation revealed sinus tachycardia and a large pericardial effusion with clinical and echocardiographic signs of tamponade. Urgent pericardial drainage was performed, yielding 620 mL of sanguineous fluid. Cytology revealed malignant cells consistent with lung adenocarcinoma. The patient underwent a cesarean delivery and was ultimately diagnosed with stage IVB EML4-anaplastic lymphoma kinase–positive lung adenocarcinoma.
Discussion
Although pericardial effusions in pregnancy can be common, cardiac tamponade is rare and requires timely intervention and further evaluation.
Take-Home Messages
Multidisciplinary collaboration is needed to determine the necessity and timing of intervention for pericardial effusions causing hemodynamic compromise in pregnancy. Sanguineous effusions should prompt evaluation for both aortic dissection and malignancy.
Key words: pericardial effusion, pregnancy, tamponade
Visual Summary
History of Presentation
A 34-year-old nulliparous woman at 35 weeks and 4 days of gestation presented to the emergency department with acute-onset chest pain and shortness of breath. Before this presentation, she had an uncomplicated prenatal course notable only for mild dyspnea thought to be pregnancy-related. On arrival to the emergency department, she described the chest pain as positional and was worse with lying on her side or back. With the onset of chest pain, she also experienced significant shortness of breath limiting her ability to do her usual activities. She also reported a 1-week history of nonproductive cough without hemoptysis or fever. She denied recent illnesses or sick contacts. Since the onset of symptoms, she continued to feel fetal movement and denied contractions.
Take-Home Messages
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Pericardial effusion with hemodynamic compromise in late gestation should prompt multidisciplinary discussions for planning the necessity and timing of intervention.
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Benign pericardial effusions can occur in relation to pregnancy; however, effusions with tamponade physiology and sanguineous pericardial effusions require prompt intervention and evaluation for secondary causes.
On arrival at the emergency department, vital signs showed tachycardia (heart rate: 130-140 beats/min) and tachypnea (respiratory rate: 22-24 breaths/min), with otherwise normal parameters. Physical examination was notable for distant heart sounds and mild jugular venous distension, without peripheral edema. Distal pulses were intact, and extremities were warm. Abdominal examination showed a gravid uterus.
Past Medical History
The patient reported a history of asthma, migraines with aura, and subclinical hypothyroidism. Her pregnancy was otherwise uncomplicated. Her family history was noncontributory.
Differential Diagnosis
The initial differential diagnosis included pericarditis, myocarditis, pulmonary embolism, aortic dissection, pneumonia, cardiomyopathy, including peripartum and stress-induced, myocardial infarction, and malignancy.
Investigations
Laboratory testing revealed mild anemia without evidence of end-organ dysfunction. Cardiac biomarkers and natriuretic peptides were normal. Electrocardiography showed sinus tachycardia with low-voltage QRS complexes (Figure 1). Point-of-care transthoracic echocardiography demonstrated a large, near-circumferential pericardial effusion with right ventricular diastolic collapse and a plethoric inferior vena cava with minimal respiratory variation (Figures 2 and 3, Video 1)—findings consistent with cardiac tamponade.
Figure 2.
Parasternal Short-Axis Mid-Papillary Transthoracic Echocardiogram View Showing Near-Circumferential Pericardial Effusion
Figure 1.
Electrocardiogram Demonstrating Sinus Tachycardia and Low-Voltage QRS Complex
Figure 3.
Parasternal Long-Axis View With Large Pericardial Effusion and Right Ventricular Diastolic Collapse
Management
After multidisciplinary discussion between emergency medicine, maternal fetal medicine, interventional cardiology, cardiothoracic surgery, and anesthesiology, the patient was taken urgently to the cardiac catheterization laboratory for pericardial drainage under continuous intraoperative fetal monitoring. Betamethasone was administered for fetal lung maturity given increased risk for preterm delivery. A total of 620 mL of sanguineous pericardial fluid was evacuated, with pericardial pressure decreasing from 33 to 8 mm Hg. Repeat echocardiogram confirmed complete resolution of the effusion and normalization of cardiac filling dynamics. Cytology and flow cytometry were sent from the pericardial fluid.
After pericardial drain placement, the patient's chest pain resolved; however, she continued to have mild tachycardia and shortness of breath. Computed tomography angiography of the chest ruled out pulmonary embolism and aortic dissection but showed nodular opacities in the right lower lung fields with enlarged paratracheal and hilar lymph nodes (Figure 4).
Figure 4.
Computed Tomography Chest Demonstrating Nodular Consolidations in the Right Lower Lobe
Ten hours postprocedure, the patient developed preterm labor (3-cm dilation, 75% effacement, −2 station). On postprocedure day 2, with continued prodromal labor and intermittent fetal heart rate decelerations, labor augmentation was initiated. Ultimately, a cesarean section was performed due to fetal intolerance of labor. Both mother and neonate tolerated delivery well. No recurrent effusions occurred after drain removal.
Outcome and Follow-Up
Pericardial fluid cytology demonstrated malignant cells concerning for lung adenocarcinoma based on immunoprofile (thyroid transcription factor-1 positive, anaplastic lymphoma kinase [ALK] rearrangement). Medical oncology was consulted and recommended positron emission tomography with computed tomography and brain magnetic resonance imaging for complete staging and to rule out another primary site of malignancy. She also underwent computed tomography–guided biopsy of the right ilium while an inpatient for next-generation sequencing to identify mutations for potential targeted therapy. Results of these studies identified EML4-ALK–positive stage IVB adenocarcinoma with metastases in the spine, pelvis, and breast.
The patient was subsequently discharged and started lorlatinib (anaplastic lymphoma kinase-1 inhibitor) monotherapy as an outpatient with palliative intent. She continues to follow medical oncology and has demonstrated computed tomography response to therapy, and there have been no recurrent pericardial effusions. Fertility preservation was discussed before initiation of therapy and was declined by the patient. Contraception was also discussed by oncology and obstetrics. Given lorlatinib can make hormonal methods of contraception less effective, an intrauterine device was recommended by oncology.
Discussion
Pericardial effusions can occur commonly in relationship to pregnancy, particularly in the third trimester, and are often benign and well tolerated.1 Effusions are typically small, transudative, and resolve spontaneously within 6 weeks of delivery.2 Management is based on expert consensus due to a lack of guidelines and depends on hemodynamic stability, etiology, and gestational age.3 Conservative management may be appropriate for small, asymptomatic effusions; however, our patient demonstrates a case in which tamponade physiology necessitates urgent pericardial drainage.
Cardiac tamponade during pregnancy is a rare but life-threatening sequela of pericardial effusions requiring immediate diagnosis and multidisciplinary coordination for the management of the effusion and potential labor and delivery.4,5 Management options include intravenous fluids for preload maintenance, pericardiocentesis, and pericardial window. In our case, pericardial drainage with continuous fetal monitoring was pursued due to clinical and echocardiographic evidence of tamponade.
Finally, the presence of a sanguineous effusion should prompt investigation for secondary causes such as malignancy or aortic dissection, because this presentation is less likely to be related to hydropericardium from pregnancy. Metastatic malignancy presenting as cardiac tamponade in pregnancy is rare, but has been reported in a few cases, and thus should remain on the differential diagnosis for sanguineous effusions.6,7 Early recognition and multidisciplinary management are crucial to optimize maternal and fetal outcomes.
Conclusions
Cardiac tamponade in pregnancy requires rapid diagnosis and multidisciplinary management by a cardio-obstetrics team. Sanguineous effusions should prompt investigation for malignancy. Early intervention can optimize maternal and fetal outcomes in hemodynamically significant cases.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
Visual Summary.
| Timeline | Events |
|---|---|
| Day 1: emergency department | A 34-y-old woman at 35 wk and 4 d of gestation presents with chest pain and dyspnea found to be tachycardic. Bedside echocardiogram with large pericardial effusion with RV chamber collapse. |
| Day 1: catheterization laboratory | Receives IV fluids. Multidisciplinary decision to proceed with urgent pericardial drainage. Pericardial pressures improve. |
| Day 2: admission to OB/GYN | Persistent shortness of breath. CT angiogram showed nodular opacites in the right lower lung fields with enlarged lymph nodes. |
| Day 2: labor and delivery | At 10 h postprocedure, the patient develops preterm labor. Due to continued prodromal labor and intermittent fetal decelerations, patient is induced and ultimately undergoes caesarean section for fetal intolerance of labor. Mother and neonate tolerate delivery well. |
| Day 4 | Pericardial fluid cytology results show malignant cells consistent with lung adenocarcinoma. PET-CET consistent with mediastinal and skeletal metastases. |
| Day 6 | CT-guided biopsy of right ilium consistent with metastatic lung adenocarcinoma. |
| Postdischarge | Patient begins lorlatinib monotherapy with demonstrated CT response. |
Appendix
Point-of-Care Ultrasound From the Emergency Department Demonstrating Large Pericardial Effusion With Right Ventricular Collapse
References
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Associated Data
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Supplementary Materials
Point-of-Care Ultrasound From the Emergency Department Demonstrating Large Pericardial Effusion With Right Ventricular Collapse