An unusual symptomatic pericardial effusion at the 24th gestational week

Abstract Background pericardial diseases during pregnancy are rare. The most common are hydropericardium – typically in the third trimester, with spontaneous resolution – and pericarditis. Echocardiogram is the imaging method of first choice for diagnosis. Clinical case a 38–year–old woman, at gestational week 24, came to the Emergency Department due to anxiety, shortness of breath, cough, gastroesophageal reflux, inappetence, and sialorrhea, all of which started with the pregnancy and worsened overtime. She underwent cardiological evaluation because of troponin discovered via blood test. The evaluation highlighted mild pericardial effusion. Hence, she was admitted to the Cardiology Department, where a progressive increase of effusion – from mild to severe (in particular in front of apical and posterior segments) without hemodynamic impact – was noted. Corticosteroid therapy was started without clinical improvement and the patient displayed orthopnea, diaphoresis, and oliguria. Through an echographic re–evaluation an hypervascular mass was identified in parasternal view. After a multidisciplinary discussion, a CT scan of thorax and abdomen with contrast (MRI was impracticable due to orthopnea) was carried out with evidence of a mediastinal solid lesion (11,5 x 7 mm) compressing superior vena cava, trachea and principal bronchial branches suggestive of lymphoproliferative disease. A pericardiocentesis was perfomed with evacuation of 400 ml of bloody fluid. The worsening of blood gas test required a tracheal intubation. Therefore, an emergency Cesarean section was executed, and a surgical biopsy of mass was taken with detection of diffuse large B–cell non–Hodgkin‘s lymphoma. Hgh doses of corticosteroids and chemotherapeutic drugs were administered and the patient was extubated after two days. After four therapeutic cycles, a PET–CT scan confirmed remission of the disease. Conclusion pregnancy is not a predisposing condition for pericardial diseases. Although pericardial involvement is benign in most cases, the use of corticosteroid therapy after the 20th week of gestation is indicated in suspected pericarditis to avoid fetal complications from NSAIDs. If there is no response, the use of advanced imaging methods (even potentially dangerous to the fetus) should not be procrastinated.