A Crisis in Late Pregnancy

A CLINICAL PROBLEM-SOLVING article by Akshay Desai from Brigham and Women's Hospital, Boston.
A 31-year-old woman in the 37th week of an uncomplicated pregnancy presented to the emergency department with sudden onset of severe bitemporal headache and shortness of breath. Her medical history was notable for hypothyroidism and pernicious anemia (both treated).
The patient was in apparent respiratory distress and reported that she felt like she was “drowning.” Her pulse was 120 beats per minute, blood pressure was 180/110 mm Hg, respiratory rate was 32 breaths per minute, and oxygen saturation was 70% while she was breathing ambient air. She was unable to lie flat without having more difficulty breathing. Funduscopic examination was normal. Cardiovascular examination revealed tachycardia, a summation gallop, and a grade 2/6 apical holosystolic murmur.
Shortness of breath in the third trimester of pregnancy has a broad differential diagnosis. Her physical examination suggests biventricular heart failure. Although malignant hypertension could account for the headache and heart failure, her funduscopic examination does not reveal papilledema or hemorrhages. This severe hypertension alone would not be expected to precipitate acute heart failure in a young person. This case highlights the critical importance of a broad differential diagnosis and careful attention to all the diagnostic clues in a complex clinical presentation.
An Interactive Medical Case related to this article is available at NEJM.org.[Original Article]