A 41-year-old woman comes to the emergency department due to worsening shortness of breath. The patient had an uncomplicated spontaneous vaginal delivery 8 days ago and was discharged from the hospital 2 days after delivery. She says the dyspnea initially occurred only when walking, but now she "cannot catch her breath" even at rest. The patient has been breastfeeding her infant every 2-3 hours and says that due to this schedule she is fatigued throughout the day. She tries to sleep when her infant does but has worsening shortness of breath when lying down. The patient has had no fevers, chills, headaches, chest pain, or abdominal pain. She continues to have vaginal bleeding that partially saturates a sanitary napkin every 4-5 hours. The patient has no chronic medical conditions and has had no previous surgeries. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37 C (98.6 F), blood pressure is 166/98 mm Hg, pulse is 70/min, and respirations are 24/min. Pulse oximetry is 92% on room air. Cardiac examination reveals a regular rhythm. Auscultation of the lungs reveals diffuse bilateral rales. There is 3+ pitting edema to the knees. Deep tendon reflexes have multiple beats of clonus. Which of the following is the most likely diagnosis in this patient?

Question

A 41-year-old woman comes to the emergency department due to worsening shortness of breath.  The patient had an uncomplicated spontaneous vaginal delivery 8 days ago and was discharged from the hospital 2 days after delivery.  She says the dyspnea initially occurred only when walking, but now she "cannot catch her breath" even at rest.  The patient has been breastfeeding her infant every 2-3 hours and says that due to this schedule she is fatigued throughout the day.  She tries to sleep when her infant does but has worsening shortness of breath when lying down.  The patient has had no fevers, chills, headaches, chest pain, or abdominal pain.  She continues to have vaginal bleeding that partially saturates a sanitary napkin every 4-5 hours.  The patient has no chronic medical conditions and has had no previous surgeries.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 37 C (98.6 F), blood pressure is 166/98 mm Hg, pulse is 70/min, and respirations are 24/min.  Pulse oximetry is 92% on room air.  Cardiac examination reveals a regular rhythm.  Auscultation of the lungs reveals diffuse bilateral rales.  There is 3+ pitting edema to the knees.  Deep tendon reflexes have multiple beats of clonus.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c037_df0c_8f63_f9572140a231_MD0005_00 This patient has preeclampsia based on a new onset of hypertension, pulmonary edema, and hyperreflexia (ie, end-organ damage). Although preeclampsia typically occurs during pregnancy, it can also occur up to 12 weeks postpartum. Preeclampsia is associated with vascular endothelial injury that leads to increased vascular permeability and a decrease in capillary colloid pressure. It is also associated with arterial vasospasm that increases capillary hydrostatic pressure. The result is third-spacing of fluid into surrounding tissues that causes peripheral edema, cerebral edema (eg, headaches, visual changes), and pulmonary edema. Pulmonary edema (eg, dyspnea, hypoxemia, decreased breath sounds) as a complication of preeclampsia is more common in the postpartum period. Treatment of postpartum preeclampsia includes seizure prophylaxis with magnesium sulfate and blood pressure control. Patients with associated pulmonary edema and fluid overload may require fluid restriction, oxygen support, and diuretics. (Choice A) Peripartum cardiomyopathy typically presents late in the third trimester or early in the postpartum period with heart failure (eg, dyspnea, cough, fatigue, pedal edema). Physical examination shows jugular venous distension and an S3. However, there is no association with hyperreflexia. (Choice C) Pregnancy and the postpartum period are associated with an increased risk for pulmonary embolism that can present with dyspnea and hypoxia; however, there is no associated hyperreflexia. (Choice D) Pulmonary hypertension can present with dyspnea and fatigue but also typically presents with exertional angina and/or syncope and a narrow split S2, not seen in this patient. (Choice E) Sheehan syndrome, postpartum panhypopituitarism, is the result of ischemic pituitary necrosis due to massive obstetric hemorrhage. Sheehan syndrome can present with postpartum fatigue; however, patients are typically hypotensive and unable to breastfeed. Educational objective: Postpartum preeclampsia, new-onset hypertension with end-organ damage, can present up to 12 weeks postpartum and can be complicated by pulmonary edema. Treatment includes magnesium sulfate for seizure prophylaxis, antihypertensives, and fluid restriction, oxygen support, and diuretics for pulmonary edema. References: Differences in clinical presentation and pregnancy outcomes in antepartum preeclampsia and new-onset postpartum preeclampsia: are these the same disorder? (http://www.ncbi.nlm.nih.gov/pubmed/27896245) Etiology and management of postpartum hypertension-preeclampsia. (http://www.ncbi.nlm.nih.gov/pubmed/21963308)

A 41-Year-Old Woman Comes to the Emergency Department Due to Worsening