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Acute Pulmonary Edema Immediately Postpartum: an Unusual Cause
Abstract Number: F-29
Abstract Type: Case Report/Case Series
Introduction: Acute pulmonary edema after vaginal delivery is a rare postpartum complication most often associated with coexisting hypertensive disorders, eclampsia, tocolytic agent administration, or maternal hemorrhage. We report a case occurring due to acute maternal mitral regurgitation (MR) in a patient with no known history of cardiac problems.
Case Report: This 27 year old (68 kg) parturient developed fulminant pulmonary edema with tachycardia and hypoxia within minutes of a full term SVD requiring intensive care transfer and stabilization. Her pregnancy, labor, and delivery had been uncomplicated without excessive fluid administration. No cardiac murmur, history of mitral valve prolapse, rheumatic fever, autoimmune disease, exercise intolerance, or hypertension had been noted in the prenatal work up. Her past medical history was significant for substance abuse (heroin, opiates, and cocaine), methadone maintenance, smoking, and peptic ulcer disease. She denied history of alcohol use or recent viral like illness. An investigation for pulmonary emboli was negative. She was noted to have developed a loud (IV/VI) holosystolic murmur with radiation to the back. A transesophageal echo showed normal left ventricular function (EF 65%), normal right ventricular function, and severe MR. TEE also indicated incomplete coaptation of the A2 and P2 cusps consistent with annular dilation, with no flail valve or vegetations. Patient was afebrile, with mild leukocytosis, and subsequent blood cultures were negative. Her symptoms improved in the ICU with diuresis, after-load reduction with lisinopril, and morphine. Her hemoglobin was 11.3, and she received 1 unit RBC’s. Her urine tested positive for opiates and cocaine. Other laboratory studies were normal except for elevated troponin levels 4 days postpartum. She was evaluated by the cardiac surgery team and severe MR was confirmed by 2-D echo, spectral and color-flow Doppler. She was initially advised medical therapy; however, due to continued paroxysmal nocturnal dyspnea, palpitations, and orthopnea, she underwent a prosthetic mitral valve replacement on the 12th postpartum day, complicated by the need for ventilation one day postoperatively.
Discussion: This is a very rare case of immediate postpartum pulmonary edema associated with acute MR but with normal ventricular function. Maternal substance abuse commonly causes cardiogenic pulmonary edema with sympathomimetic use; most commonly coexistent with myocardial vasopasm and ischemia, hypertension, arrhythmias, or diastolic dysfunction. Acute mitral valve annular distension and dysfunction probably occurred immediately postpartum due to the high cardiac output resulting from recent valsalva and pushing efforts, and in temporally associated cocaine ingestion and coronary vasospasm.
References: 1. http://jicsagepub.com/content/19/4/183 2. J Amer Col of Cardiology 48 (3) 2006