A 27-year-old female patient presents to the emergency department (ED) with a chief complaint of fatigue and shortness of breath over the last two weeks.

She reports generally low energy levels over the past month. She developed mild dyspnea on exertion two weeks ago. She felt short of breath simply trying to get out of bed this morning, and this prompted her to seek evaluation.

The patient has otherwise been healthy and reports no significant past medical history. Her social history is unrevealing. She denies having a family history of heart disease. When asked about current or recent pregnancy, the patient states that she delivered a healthy, full-term baby four months ago, preceded by an uncomplicated pregnancy.

On exam, the patient generally appears well.

Vital signs:

• Temperature 37.1 °C
• Heart rate 101
• Respiratory rate 28
• Blood pressure 130/76
• Oxygen saturation 90 percent

Her physical examination is notable for stage 2+ pitting edema of the bilateral lower extremities, and the presence of bibasilar crackles on auscultation of the lungs. No abnormal cardiac sounds are appreciated. Her abdomen is soft, nontender, and nondistended. Prominent jugular veins are appreciated.

Differential Diagnosis

The differential diagnosis on this patient includes myocardial infarction, congestive heart failure, myocarditis, pericarditis, pulmonary embolism, pneumonia, pleural effusion, pulmonary edema, anemia, hypothyroidism, cardiac arrhythmia, aortic dissection, and peripartum cardiomyopathy.

Workup

The evaluation of this patient’s chief complaint includes a 12-lead ECG and a chest radiograph. Laboratory tests including troponin, brain natriuretic peptide (BNP), complete blood count, electrolyte panel, and a pregnancy test should be obtained. Point-of-care bedside echo may be helpful to evaluate the global systolic function of the left ventricle, to assess for significant right ventricular enlargement, and to evaluate for the presence of a pericardial effusion. Point-of-care ultrasound of the lungs may reveal the presence of B-lines, which would be concerning for pulmonary edema in this patient. Pleural effusions are also typically apparent on lung ultrasonography.

Ambulatory pulse oximetry test may unmask worsening hypoxia in the setting of physical activity.

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Management

Pregnancy-related cardiovascular disease is a rare but serious complication of pregnancy and accounts for a significant proportion of maternal morbidity and mortality. Cardiovascular disease is the second most common cause of pregnancy-related death in the United States, and is the leading cause of pregnancy-related death among non-Hispanic Black patients.¹ Cardiovascular disease during or after pregnancy—collectively representing an array of conditions involving disease and dysfunction of the heart and vascular system—encompasses the diagnoses of myocardial infarction (including spontaneous coronary artery dissection), cardiac arrhythmia, congestive heart failure, aortic dissection, and peripartum cardiomyopathy.

The mortality rate varies by condition, time to presentation, the patient’s access to specialty care, and patient comorbidities. A global registry of peripartum cardiomyopathy (PPCM) reports that fewer than half of patients who experience PPCM will completely recover their left ventricular function.² The key to making these diagnoses is identifying which patients are at risk. Because the risk for pregnancy-related cardiovascular disease extends many months past the point at which the pregnancy ends, it is recommended that all pregnancy-capable patients be screened for current or recent pregnancy. The most straightforward means to ascertain current or recent pregnancy is for the ED clinician to ask the patient, “Are you pregnant, or have you been pregnant in the last 12 months?”

The acute management of cardiovascular disease during pregnancy or in the postpartum period centers on recognizing the condition, supporting oxygenation and ventilation through the provision of supplemental oxygen when necessary, optimizing the patient’s volume status and myocardial function, connecting the patient to timely subspecialty care, and—if necessary—intervening. Many of the medications used in the acute management of cardiovascular emergencies—diuretics, beta blockers, ACE inhibitors, and angiotensin receptor blockers—do not have robust data on their usage during pregnancy or lactation but should not be withheld in life-threatening circumstances. Consultation with cardiology and maternal–fetal medicine specialists is strongly recommended when available.

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ACEP and the American College of Obstetricians and Gynecologists (ACOG) together developed an algorithm to assist emergency physicians in the diagnosis and management of patients with pregnancy-related cardiovascular disease.³ The algorithm is shown in Figure 1.

Case Outcome

The patient’s bedside ultrasound was concerning for the presence of three or more B-lines in numerous lung windows, and the patient’s left ventricular ejection fracture appeared globally reduced. The BNP was markedly elevated. ECG revealed normal sinus rhythm with no acute ischemic changes. First high-sensitivity troponin was slightly above reference range. The patient was admitted to an inpatient telemetry bed for continued workup and consultations with cardiology and maternal–fetal medicine due to concern for peripartum cardiomyopathy.

Dr. White is chair of ACOG’s Obstetric Emergencies in Non-Obstetric Settings Project and an emergency physician at University of New Mexico, Albuquerque, N.M.

References

1. Trost S, Busacker A, Leonard M, et al. Pregnancy-related deaths: data from Maternal Mortality Review Committees in 38 U.S. States, 2020. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published May 28, 2024. Accessed November 22, 2024.
2. Hoevelmann J, Engel ME, Muller E, et al. A global perspective on the management and outcomes of peripartum cardiomyopathy: a systematic review and meta-analysis. Eur J Heart Fail. 2022;24(9):1719-1736.
3. The American College of Obstetricians and Gynecologists. Identifying and managing obstetric emergencies in nonobstetric settings. Published 2024. Accessed November 10, 2024.