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Late Pregnancy Crisis 
Massachusetts General Hospital
Samantha Jennings - OB-GYN consultant
Morgan Brown - Resident
Andrew Minnows - Resident
Julia Teider - Resident
Mrs Ellis
31
Married, Pregnant, 37th week
- sudden onset of severe bitemporal headache
- shortness of breath
- respiratory distress -> made worse by lying flat
- felt as if she was drowning
- uncomplicated pregnancy, normal BP.
- last prenatal visit 1 week ago -> BP = 120/70 ; HR=72bpm. +17 kg in pregnancy
- two previous pregnancies -> spontaneous abortion in the first trimester
- hypothyroidism-> levothyroxine, 150microg daily
- pernicious anemia
- 1mg of vitamin B12 intramuscularly monthly + prenatal vitamins
- no known allergies + no smoking
- BP=180/110 when supine, equal in both arms
- jugular venous pressure = 15 cm H20
- heart rate = 120bpm
- diffuse but non displaced apical impulse, summation gallop, apical holosystolic murmur grade 2/6
- no edema in the legs
- respiration = 32 bpm
- O2 sat 70% when breathing ambient air
- bibasilar rales, persisting with cough and deep breathing
- normal reflexes
- normal optic fundi.
- normal abdominal examination - mild contractions every 5 minutes
- cervix dilated by 1 cm and 80% effaced, with membranes intact
- fetal heart sounds normal at 130bpm.
- high BP -> preeclampsia + gestational hypertension
- heart failure
- peripartum cardiomyopathy
- cerebral aneurysm
- aortic dissection
- acute MI
- acute rheumatic fever
- amniotic-fluid embolism
- systemic lupus erythematosus
- peripartum cardiomyopathy
- full blood count
- ECG
- chest radiography, with abdominal shielding
- transthoracic echocardiogram
- CT of the head
Bloods
- white cell count high at 21,800 per mm3
- hematocrit high at 45%
- creatine kinase at 1,353 U/liter
- troponin I at 23.3 U/liter
- aspartate aminotransferase at 74 U/liter
- spot urine protein: creatinine ratio of 4,27
ECG -> Poor R-wave progression and nonspecific ST–T wave changes
X-ray -> extent of the pulmonary vascular congestion greater normal in late pregnancy
Echocardiogram -> global left ventricular dysfunction, with moderate left ventricular dilatation and a left ventricular ejection fraction of 20% + moderate mitral regurgitation
CT scan -> normal
pulmonary edema as a result of severe preeclampsia, complicated by peripartum cardiomyopathy
- intravenous labetalol
- hydralazine, furosemide
- administer bilevel positive airway pressure
- magnesium sulfate
- prescriptions for digoxin, lisinopril, and metoprolol succinate
- subsequent pregnancies may be hazardous
- good response to treatment. Normalization of blood levels. Follow-up in two weeks.