Question of the week

Your ESCardioEd challenge by Pimpimol Yooprasert and team, Faculty of Medicine Ramathibodi Hospital, Mahidol University - Bangkok

A 22-year-old, 34 weeks pregnant, was referred due to massive hemoptysis.
Personal history: first episode when aged 17 and 7 months pregnant, patient gave birth to a preterm baby who died 2 weeks later of unknown cause, no autopsy.
Five months prior to this admission, she had hemoptysis and acute dyspnea after traveling on a long-distant bus and diagnosed with pneumonia.
Examination: Tachypnea with desaturation, diagnosed with heart failure. Pulse oximetry measured from her left hand showed a saturation of 91 % on room air, and 96 % while on 10 LPM oxygen mask. There was no central or peripheral cyanosis and no clubbing of fingers or toes , but pulse oximetry showed more degree of desaturation of her feet, measured 74 %. On auscultation, there was loud P2 and pansystolic murmur grade III/VI at left lower parasternal border area. Lungs were clear and minimal pedal oedema was noted.
Chest x-ray: cardiomegaly, enlarged pulmonary trunk and right pulmonary artery, increased pulmonary vasculature, and a patchy infiltration at left upper lung zone. ECG: normal sinus rhythm with evidence of right ventricular hypertrophy and right axis deviation.
Blood test: mild normocytic anaemia (Hb 11.4 g/dL, Hct 38.0 %, MCV 81.7 fL), thrombocytopenia with platelet count 88000 /mm3, and normal white blood cell series. Echocardiogram is below.




What would you do next?

A. Emergency baby delivery
B. Right heart catheterization
C. Counseling with multidisciplinary team
D. Bedrest and therapy until delivery


Answer :

Correct answer is C.
Bedside ultrasound revealed oligohydramnios and a single living foetus in a breech presentation. Foetal tracing showed reassuring pattern. Corticosteroid was given to promote foetal lung maturation, and elective Caesarian section was scheduled. Sildenafil was started on the night when she arrived, with careful monitoring of vital signs and clinical symptoms.
Right heart catheterisation was performed a day later, demonstrating severe pre-capillary pulmonary hypertension (mPAP 88 mmHg, PAWP 10 mmHg, PVR 17 WU) without oxygen step-up pattern.
CT scan revealed PDA (see below) Sildenafil was titrated up to 40 mg orally three times per day, without adverse event. Patient discharged after 10 days of admission, without hemoptysis or dyspnea .