This 32-year-old pregnant woman was admitted to Qingdao Municipal Hospital with menopause for 7 months, fetal movement for 3 months and fever for 1 day. Relevant examinations were completed after admission with the following results: WBC count 9.71×10^9/L, neutrophil count 8.50×10^9/L, lymphocyte count 0.60×10^9/L, erythrocyte count 3.63×10^12/L, hemoglobin 112.00g/L, hematocrit 34.00%, the whole process C-reactive protein 47.60mg/L, alanine aminotransferase 106.61U/L, aspartate aminotransferase 214.06U/L, creatine kinase 542.50U/L, creatine kinase isoenzyme 81.90U/L, and creatinine 46.28umol/L. The ECG showed sinus rhythm and sinus tachycardia (Fig. 1). The computed tomography (CT) image of lung is normal. The echocardiogram demonstrated right atrial enlargement, decreased systolic function of right ventricle (mild), pericardial effusion (small), normal left ventricular wall thickness and movement, an EF of 56%, an estimated right atrial pressure of 8mmHg, and an estimated pulmonary artery systolic pressure of 21mmHg.
On Day 3 postadmission, the patient's temperature was 38℃. Results of laboratory examinations were as follows: myoglobin 64.23ng/ml, creatine kinase isoenzyme 37.81ng/ml, high-sensitivity troponin I 12.181ng/ mL, and BNP 10755.42pg/ml. Results of routine coagulation testing were as follows: prothrombin time 13.30s, activated partial thrombin time 32.60s, thrombin time 15.80s, D-dimer quantitative 6.10ug/ml, and fibrinogen 4.99g/L. The ECG showed sinus tachycardia, complete right bundle branch block and ST-T changes (Fig. 2). As the cause of the pregnant woman's fever was difficult to make clear, a consultation was performed by the department of cardiology, the department of respiratory medicine, the department of nephrology, the department of immunology and rheumatology as well as the department of medical imaging, with a diagnosis of acute myocarditis. The pregnant woman's condition deteriorated rapidly, and emergency cesarean section was performed under lumbar epidural anesthesia. After the patient entered the operating room, we routinely monitored ECG, SpO2 and NBP, as well as opened venous access. The patient underwent combined spinal-epidural block, with the space between lumbar 3–4 spinous processes (L3-4) as the puncture site. After successful puncture, injection of 2-2.5ml ropivacaine (0.66%) for about 30s. After anesthesia, the sensory level was controlled below the T8 level. During the surgery, oxygen was inhaled via mask at 5 L/min to maintain blood pressure within +/- 20% of the baseline value. If intraoperative NBP was < 90 mmHg (1mmHg = 0.133kPa) or it decreased by more than 20% of the baseline value, ephedrine 5mg was injected intravenously. If HR was < 50 beats/min, atropine 0.5 mg was injected intravenously. Intravenous patient-controlled analgesia (butorphanol 0.1mg/ml + tropisetron 50 g/ml, diluted with normal saline to a total volume of 100 ml) was used in acute postoperative pain management. After the operation, the patient was sent to ICU. A live baby was delivered during the operation. The Apgar score was 5–6. After neonatal resuscitation, the live baby was transferred to the neonatal department.
On Day 4 postadmission, the patient's cardiac function continued to deteriorate after antiviral therapy. The results of laboratory examinations were as follows: myoglobin 129.50ng/ml, creatine kinase isoenzyme 48.65ng/ml, high-sensitivity troponin I 14.237ng/ mL, and b-amino-terminus natriuretic propeptide 15958.25pg/ml. Echocardiography showed left ventricular wall motion abnormalities, decreased left ventricular systolic function (mild to moderate), pericardial effusion (small amount),ECG revealed acute anterior-wall myocardial infarction with right bundle branch block (Fig. 3). It was believed that the patient would soon die without ECMO support. Therefore, a venoarterial ECMO circuit was placed via the right femoral artery and the right femoral vein immediately. The patient's condition stabilized after initiation of ECMO. The patient's clinical status remained stable during the next 7 days, but we could not wean her from the ECMO circuit.
After ECMO therapy, cardiac function was significantly improved, and the concentrations of hypersensitive troponin and b-type amino-terminal natriuretic peptide were significantly decreased. ECG showed sinus tachycardia and ST-T changes (Fig. 4). The patient was slowly weaned from pressor support, and her heart function gradually improved. Repeated echocardiography demonstrated improved ventricular function. The patient could now be weaned from the ECMO circuit, and the vascular cannulas were removed on Day 10 postadmission. The echocardiogram demonstrated normal left ventricular systolic function, normal left ventricular diastolic function, and an EF of 59%. On Day 22, she and her baby were discharged from the hospital.