Severe Preeclamptic Patient with Pulmonary Edema and Peripartum Cardiomyopathy

Mehta, P, MSIV1, Kantor, HM, M.D. 2, Beckwith, AW, M.D.2

University of New England College of Osteopathic Medicine, Biddeford, ME1; and Berkshire Medical
Center, Department of Obstetrics and Gynecology, Pittsfield, MA2

Introduction: Preeclampsia is a multisystem disorder that which occurs in about 5-8% of pregnancies in
the United States. Fluid management of patients before, during and after delivery is a challenge to
physicians. Severe preeclamptic patients add to the challenge with deficits of 600-800ml/m2 resulting in a
hypovolemia state with circulating volumes less so than in normal pregnancy. We report a case of a
patient with severe preeclampsia that developed pulmonary edema due to fluid overload complicated by
peripartum cardiomyopathy.

Case: A 36-year-old previous healthy gravida 1 para 0 at 37 weeks of gestation was brought to the
Emergency Room after witnessed having a seizure at home. On arrival the patient began seizure activity
again for 30 seconds duration while remaining unresponsive, convulsive and diaphoretic. The patients'
blood pressure was 180/105 with a heart rate of 114. Laboratory studies were within normal limits and a
catheterized urine specimen demonstrated 3+ protein. On the basis of blood pressure measurement,
laboratory findings and seizure activity the patient was diagnosed with preeclampsia. A bolus dose of
Magnesium Sulfate (6 gm) along with Labetalol HCL (100mg) was immediately given. After
stabilization and fetal evaluation the patient was taken to the operating room for primary C-section
delivery. The patient was observed closely in the labor and delivery unit with frequent monitoring of vital
signs and fluid output. A magnesium drip was continued at 2gms/hr with magnesium levels collected
every 4 hours. Fluid input and outputs were monitored every hour. Twelve hours after delivery the
patients input was 5349 cc and output was 926 cc. Hetastarch 6% was ordered and given 150cc/hr for
2hrs due to oliguria and presumed hypovolemia. Four hours later fluid input was 6389 cc and urine output
was 1138cc. Another dose of Hetastarch 6% was given 100cc/hr to the patient for 2 hrs. Six hours after
the second dose of Hetastarch 6% was given the patient developed shortness of breath and chest pain. The
nurse was called in and noted breath sound crackles on the right side of the chest. A CT with IV contrast
was immediately ordered and showed bilateral interstitial edema and bilateral consolidation in the lower
lobes. Due to hypoxemia and worsening dyspnea, the Medical Emergency Team was called to stabilize
the patient. The patient continued to have trouble breathing and was intubated and transferred to the
Intensive Care Unit to be carefully monitored. At the ICU the patient continued on a Furosemide drip
(5mg/hr). Cardiology was consulted and an echocardiogram showed an ejection fraction of 15-20% with
normal residual volume. At this point the consensus was that the pulmonary edema was due to
superimposed volume load complicated with peripartum cardiomyopathy. The patient was extubated and
followed in the ICU for 3 days with vitals and fluid input and output closely monitored. Urine output
improved and blood pressure was stabilized. Cardiovascular therapy consisting of Lisinopril (2.5 mg
daily), Carvedilol (3.125 mg BID), Spironolactone (25 mg daily) and oral Furosemide (40mg BID) was
carried out. A repeated echocardiogram showed an improvement of ejection fraction to 35%. A repeat
chest x-ray showed no consolidation or infiltrate, no pulmonary edema and normal cardiac silhouette.
After spending 9 days in the hospital the patient was discharged in stable condition.

Discussion: Pulmonary edema is a common complication in severe preeclamptics often due to volume
overload and improper fluid management postpartum. Decreased urine output (oliguria) as a result of
poor fluid intake and stress of surgery adds to the difficulty in managing these patients. Unfortunately,
there is little evidence and a lack of consensus regarding the proper management of fluids in preeclamptic
patients. Carefully monitoring homodynamic parameters when patients present with volume instability is
essential. Determining appropriate fluid supplement is important in correcting the hypovolemia.
Managing these patients requires a collaborative effort from obstetric, anesthetic and nursing staff in
monitoring and managing the fluids.