Of a Tortuous Nature

Introduction

Information about a real patient is presented in stages (boldface type) to expert clinicians (Drs Rubin, Grinspan, and Ginns), who respond to the information, sharing their reasoning with the reader (regular type). A discussion by the authors follows.

Patient presentation: A 42-year-old recently postpartum, multiparous woman presented to the emergency department with dyspnea on exertion. Full-term pregnancy and delivery 11 days earlier had been uncomplicated. Five days before admission the patient experienced progressive exercise intolerance, fatigue, and peripheral edema associated with chest discomfort and palpitations. On the evening before presentation, she developed paroxysmal nocturnal dyspnea. Her other medical and surgical history was unremarkable. Obstetric history was notable for 11 pregnancies, with 10 uncomplicated spontaneous vaginal deliveries and 1 prior miscarriage. She was not prescribed any home medications, denied allergies, and had no toxic habits. There was no family history of cardiac or clotting disorders. She denied syncope, fever, cough, sore throat, rash, bleeding, and flank pain.

Dr Ginns: The differential diagnosis of postpartum dyspnea is broad and includes syndromes specifically associated with pregnancy and common syndromes unmasked by the peripartum state of both cardiovascular and noncardiovascular etiologies (Table).¹ The story of progressive dyspnea, edema, and orthopnea suggests a heart failure syndrome. The patient’s increased age and multiparity place her at higher risk for peripartum cardiomyopathy, which may manifest toward the end of pregnancy or within months thereafter. It will be helpful to investigate the peripartum transfusion and tocolytic requirements, which are associated with the development of pulmonary edema. Acute myocardial ischemia and pulmonary embolism must be ruled out.

Patient presentation (continued): In the emergency department, the patient appeared well at rest. Her heart rate was 96 and blood pressure was 148/79 mm Hg. Oxygen saturation was 97% at rest, but, on ambulation, …