Peripartum Pericarditis and the Potential Risks to Breastfeeding Infants

Oct 08, 2019   |  Eli Simsolo, MD; Michael Chetrit, MD, FACC; Allan L. Klein, MD, CM, FACC
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A 30-year-old G1P1 female with a past medical history significant for fibrosing mediastinitis secondary to pulmonary histoplasmosis (treated with itraconazole in 2015) and acute pericarditis presents to cardiology clinic for a follow-up visit. She was diagnosed with acute pericarditis approximately two months prior to going into labor after complaining to her family physician of persistent pleuritic chest pain. Given that she was pregnant, she was initially prescribed single therapy of prednisone 20 mg daily and her symptoms subsided shortly thereafter. However, 2 months after her initial diagnosis she re-presented with chest discomfort and a large pericardial effusion that required drainage after an emergent delivery. Post-partum, she has been treated with ibuprofen and colchicine.

She presents today, four weeks after delivery, with ongoing symptoms. She remains on ibuprofen and colchicine. She reports worsening dyspnea, especially on exertion. Furthermore, she endorses chest pain that is worse in the supine position. Her inflammatory markers reveal a sedimentation rate of 38 mm/hr [normal 0 - 20 mm/hr] and an ultra-sensitive C-reactive protein level of 51.6 mg/L [normal <3.1 mg/L]. Her ECG is shown in Figure 1, and previous echocardiogram in Figures 2 and 3. A cardiac magnetic resonance imaging (MRI) was ordered to further assess the pericardium and pericardial effusion.

Figure 1

Figure 1
Figure 1: Electrocardiogram displaying ST elevations in multiple leads, PR elevation in aVR and, PR depressions in I, II, aVF, and V3-V6 in a pattern consistent with pericarditis.

Her echo (below) from four weeks ago reveals the large circumferential pericardial effusion with tamponade features that required pericardiocentesis at the time.

Figure 2

Figure 2
Figure 2: Parasternal long-axis view revealing almost complete collapse of the right ventricle (red arrow) due to large circumferential pericardial effusion (*)

Figure 3

Figure 3
Figure 3: Parasternal short-axis view during systole (left) and diastole (right) revealing little or no diastolic expansion of the right ventricle.

Figure 4

Figure 4
Figure 4: Cardiac MRI (on day of office visit) delayed sequence after gadolinium injection revealing mild pericardial thickening, and qualitatively moderate circumferential increased pericardial delayed enhancement (arrow).

Review of her inpatient computed tomography (CT) chest revealed calcified mediastinal and right hilar lymph nodes in keeping with her history of fibrosing mediastinitis.

Out of concern for reactivation of pulmonary histoplasmosis, infectious disease specialists decide to start the patient on an anti-microbial. She is four weeks post-partum and would like to begin breastfeeding. She is worried about taking these medications while breastfeeding.

What is the best course of action in regards to her treatment regimen?

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