A 40-year-old woman is seen 48 hours after an uncomplicated repeat caesarean delivery at 39 weeks gestation. She reports sudden-onset shortness of breath and a nonproductive cough. The patient has no fever, chills, nausea, vomiting, or chest pain. Her prenatal course was uncomplicated. She has no chronic medical conditions. The patient's previous pregnancy was uncomplicated; she had a term caesarean delivery for breech presentation.
On examination, the patient appears distressed. Blood pressure is 196/112 mm Hg, pulse is 120/min, and respirations are 32/min. Pulse oximetry is 86% on room air. Auscultation of the lungs shows diffuse inspiratory crackles bilaterally. Jugular venous pressure is normal. Cardiac sounds are normal and there are no murmurs or additional sounds. Abdominal examination is normal. There is 2+ pedal edema to the bilateral mid-calves.
Laboratory results are as follows:
Chest x-ray reveals bilateral diffuse alveolar infiltrates. ECG shows sinus tachycardia and upsloping ST-segment depressions in the inferior lateral leads.
Which of the following is the most likely diagnosis in this patient?

Question

A 40-year-old woman is seen 48 hours after an uncomplicated repeat caesarean delivery at 39 weeks gestation.  She reports sudden-onset shortness of breath and a nonproductive cough.  The patient has no fever, chills, nausea, vomiting, or chest pain.  Her prenatal course was uncomplicated.  She has no chronic medical conditions.  The patient's previous pregnancy was uncomplicated; she had a term caesarean delivery for breech presentation.
On examination, the patient appears distressed.  Blood pressure is 196/112 mm Hg, pulse is 120/min, and respirations are 32/min.  Pulse oximetry is 86% on room air.  Auscultation of the lungs shows diffuse inspiratory crackles bilaterally.  Jugular venous pressure is normal.  Cardiac sounds are normal and there are no murmurs or additional sounds.  Abdominal examination is normal.  There is 2+ pedal edema to the bilateral mid-calves.
Laboratory results are as follows:
 Chest x-ray reveals bilateral diffuse alveolar infiltrates.  ECG shows sinus tachycardia and upsloping ST-segment depressions in the inferior lateral leads.
Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec193a_970c_d1be_853d_6ff459395f14_MD0002_00 This patient with respiratory distress and crackles associated with new-onset hypertension and significant (3+) proteinuria has postpartum preeclampsia complicated by pulmonary edema. Preeclampsia typically presents from 20 weeks gestation and commonly manifests in the third trimester. However, it can occur after delivery and up to 6 weeks postpartum; the majority of cases occur within 48 hours of delivery. During pregnancy, common clinical features include headache, epigastric/right upper quadrant pain, and visual changes. In the postpartum period, pulmonary edema is a common presentation, likely due to preeclampsia-induced renal changes (eg, proteinuria) exacerbating physiologic postpartum fluid shifts. Other causes of postpartum pulmonary edema include capillary leak, left heart failure (eg, peripartum cardiomyopathy), and iatrogenic volume overload. Treatment of postpartum preeclampsia includes blood pressure control and administration of magnesium sulfate for seizure prophylaxis. Fluid restriction, oxygen support, and diuretics can be considered for patients who have preeclampsia complicated by pulmonary edema. (Choice A) Acute coronary syndrome can cause hypertension, dyspnea, and nonspecific ECG changes; however, the presence of significant proteinuria, absence of chest pain, and normal cardiac examination make preeclampsia, rather than acute coronary syndrome or its complications (eg, papillary rupture), a more likely cause of this patient's findings. (Choice B) Amniotic fluid embolism can cause an acute onset of dyspnea; however, the majority of patients have hypotension (eg, cardiogenic shock) and disseminated intravascular coagulation (eg, bleeding, bruising). (Choice C) Aspiration presents with acute-onset dyspnea, hypoxia, and diffuse crackles on auscultation; however, chest x-ray typically shows segmental rather than diffuse infiltration. Significant hypertension and proteinuria are not typical findings. (Choice D) Peripartum cardiomyopathy can present with dyspnea, cough, pedal edema, and hypertension in the third trimester or postpartum period. Proteinuria is not a characteristic finding, and this patient has no jugular venous distension or S3 to suggest heart failure. Educational objective: Preeclampsia, defined as new-onset hypertension and proteinuria, can present from 20 weeks gestation to 6 weeks postpartum and can be complicated by pulmonary edema. Treatment includes blood pressure control and seizure prophylaxis (ie, magnesium sulfate). __________ References: Cardiopulmonary complications of pre-eclampsia. (http://www.ncbi.nlm.nih.gov/pubmed/19464506) Etiology and management of postpartum hypertension-preeclampsia. (http://www.ncbi.nlm.nih.gov/pubmed/21963308)

A 40-Year-Old Woman Is Seen 48 Hours After an Uncomplicated