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Acute Postpartum Pulmonary edema: A Case Report

Article in Bangladesh Journal of Obstetrics & Gynaecology · July 2020

DOI: 10.3329/bjog.v33i2.43572

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Nahreen Akhtar Namkha - Dorji

Bangabandhu Sheikh Mujib Medical University JIgme Dorji Wangchuck National Referral Hospital
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Bangladesh J Obstet Gynaecol, 2018; Vol. 33(2): 157-159

Case Reports
Acute Postpartum Pulmonary edema: A Case Report
NAHREEN AKHTAR1, NAMKHA DORJI2, TABASSUM PARVEEN3, YESHEY DORJEY2,
FIROZA BEGUM4,SAMIRA HAYEE5, SABINA KARIM6

Abstract:
A 30 year old, G2P1, pregnancy complicated with moderate anaemia, preeclampsia and
gestational diabetes mellitus was admitted at 37+ week pregnancy with less fetal movement
and premature rupture of membrane. A healthy baby was delivered by caesarean section
with uneventful perioperative period. On 4th post operative day, she developed severe acute
pulmonary edema where intubation was done instantly and ventilated in the intensive care
unit. Patient recovered and extubation done on 6th postoperative day. A healthy mother and
a healthy baby were discharged on 10th postoperative day.
Key words: Pulmonary edema, post partum

Introduction: administration is recognized as significant risk factor

Postpartum pulmonary edema is an uncommon but for developing acute pulmonary edema. A high
a life threatening event in pregnancy which causes degree of clinical suspicion in a patient with acute
significant morbidity and mortality in women with respiratory distress, and proper auscultation of lungs
preeclampsia. The Scottish Confidential Audit of supported by chest X ray is the cornerstone of
Severe Maternal Morbidity, one of the largest diagnosis. Multidisciplinary team approach with
maternal morbidity audits, reported that acute intensive care unit (ICU) facility is required to save
pulmonary edema was the fourth most common life of patients with severe acute pulmonary oedema.
cause of maternal morbidity.1 It is also frequently the Herein, we report a case of a severe life threatening
reason for intensive care admission 2, and may occur postpartum pulmonary oedema in a young female
during the antenatal, intrapartum or postpartum who had preeclampsia, gestational diabetes mellitus
periods. The mechanism of acute pulmonary edema and moderate anaemia.
depends on hemodynamic state of pregnant women.
Case Report:
Cardiac structural and functional abnormalities along
A 30 year old woman, G2P1, was admitted to the
with alterations in fluid balance and proteinuria may
Fetomaternal Unit, Department of Obstetrics and
be the cause. Acute hypertensive crisis that cause Gynaecology, Bangabandhu Sheikh Mujib Medical
pulmonary edema may occur through sympathetic (BSMMU) at 37+ weeks of gestation with less fetal
nervous activation, causing acute venoconstriction movement for last 8 hours and per vaginal watery
and vasoconstriction, which leads to discharge for last 3 days. She was diagnosed as a
increased afterload and redistribution of fluid from case of preeclampsia and gestational diabetes
peripheral circulation to pulmonary vessels. This mellitus since 28 weeks gestation. She was on Tab.
causes alveolar fluid accumulation and reduced Alpha Methyldopa 250mg TDS and short acting
oxygenation and increase in cardiac output due to insulin (Actrapid) 4+6+8 units for preeclampsia and
reduce oxygen delivery to kidney. Unrestricted fluid gestational diabetes mellitus respectively, which were

1. Professor, Department of Fetomaternal Medicne, BSMMU, Dhaka.

2. Resident (Phase B), Department of Obstetrics and Gynaecology, BSMMU, Dhaka.
3. Associate Professor, Department of Fetomaternal Medicine ,BSMMU, Dhaka
4. Chairman, Department of Fetomaternal Medicine ,BSMMU, Dhaka
5. Internee, Chottogram medical College, Chottogram
6. Junior consultant (Paediatrics), Kurmitola General Hospital, Dhaka Cantonment, Dhaka.
Address of Correspondence: Prof. Nahreen Akhtar, Professor, Department of Fetomaternal Medicne, BSMMU, Dhaka.
E-mail: [email protected], Cell: 01711544687.
Acute Postpartum Pulmonary edema: A Case Report Nahreen Akhtar et al.

under good control. She was anaemic, pulse rate The ventilation was weaned off on day 6 as her
was 80 beats per minute and blood pressure was condition improved. Healthy mother with a healthy
140/90 mmHg. Mild bilateral pitting ankle oedema baby were discharged on postoperative day 10.
was present. Clinical examination confirmed viable
She came to follow up on 28th Feb 2016. Blood
fetus with premature rupture of membrane with
pressure was under controlled with Tab Nidipro. The
breech presentation. Review of her antenatal history
follow up echocardiograph revealed EF-67% and
and investigations records revealed that she was on
there was no evidence of cardiac pathology. She did
routine follow up at our Outpatient Department (OPD).
not have any complaint.
An elective lower uterine caesarean section (LUCS)
under spinal anaesthesia was performed on the next Discussion:
day. A live male baby weighing 2600 gram was Acute pulmonary edema is a life threatening condition
delivered. Her postoperative recovery was uneventful that occurs more often in pregnancies than in non
up to day 3. However, her postoperative haemoglobin pregnant state. It complicates about 0.08% of
was 7.7 g/dl and she was transfused 2 units of packed pregnancies.3 Based on patient presentation with
red cells. Her preoperative haemoglobin was 9.0 g/ acute postpartum dyspnoea, these condition can be
dl. Her blood pressure was controlled with Cap categorised into pathologies not associated with
Nidipro (Atenolol 50mg & sustained release pulmonary oedema (pulmonary embolism, sepsis
Nifedipine 20mg combination) BD and blood sugar and aspiration of gastric content) and pathologies
by injection Actrapid insulin 100iu/ml 4 units TDS associated with pulmonary oedema include
subcutaneously. cardiogenic and noncardiogenic causes.
On fourth postoperative day, she developed sudden Noncardiogenic pulmonary edema include iatrogenic
onset severe respiratory distress: she was gasping, fluid overload, thyroid disease, drug induced
cyanosed, GCS (Glasgow Coma Scale) was 3/15, pulmonary edema (e.g., tocolytic therapy and
pulse rate was 110bpm, blood pressure was 190/ oxytocin), acute respiratory distress syndrome
110 mmHg, crepitation was present in bilateral lung (ARDS), and preeclampsia related pulmonary
fields. A provisional diagnosis of acute postpartum edema. Peripartum cardiomyopathy, preeclampsia
pulmonary edema was made. SpO2 on air dropped induced cardiomyopathy, underlying structural heart
to 21%. On administering O 2 at 15 L/min via diseases or valvular heart diseases, and myocardial
facemask, SpO2 was 50%. She was given ischemia are examples of cardiogenic causes of
intravenous hydrocortisone 200mg and intravenous pulmonary edema.4
furosemide 60mg (3 ampoules). She was intubated Disturbance in any of the key determinates of
immediately and shifted to the intensive care unit, cardiovascular function and fluid flow into the
BSMMU. A urinary catheter was inserted and urine pulmonary interstitium could result in acute
output monitored. pulmonary edema.5
ABG (arterial blood gas) showed pH of 7.368, Hb- Acute pulmonary edema can occur in antenatal,
9.2 g/dl, no ischemic changes in the ECG, urine intrapartum and postpartum periods. Patients present
protein was ++. Chest X ray massive pulmonary with sudden onset acute respiratory distress. It is a
congestion. Echocardiograph showed good LV frequent reason for intensive care unit admission. 2
function with EF of 67%. Cardiac enzyme (Troponin
I) was negative. Provision of symptomatic relief, improvement of
oxygenation, maintenance of cardiac output,
In the ICU, oxygen saturation was maintained at perfusion of vital organs and reduction of excess
100%. She was managed with intravenous antibiotics extracellular fluid constitute the goals of treatment of
(Injection Ceftriaxone 1g 12 hourly, Injection acute pulmonary edema. Underlying cause has to
metronidazole 500mg 8 hourly and injection
be identified and targeted treatment initiated. Nitrates,
gentamicin 80mg 8 hourly). Intravenous furosemide
diuretics, morphine and inotropes are drugs needed
was continued. Her BP was controlled with
for treatment. Ventilator support is required for some
intravenous Labecard (Labetalol) 200mg 12 hourly.
cases.6
Her blood sugar was monitored closely and
maintained with subcutaneous Actrapid insulin. Her Intraveneous furosemide (bolus 20 - 40mg over 2
clinical condition improved. minutes) is used to promote venodilation and diuresis

158
 Bangladesh J Obstet Gynaecol Vol. 33, No. 2

with repeated doses of 40–60mg after approximately protocol for such patients. A vigilant monitoring and
30 minutes if there is an inadequate diuretic response taking prophylactic measures to prevent development
(maximum dose 120mg). 7 In this case we managed of acute pulmonary edema in those women at risk
with 60mg of furosemide initially. Some studies have would be an ideal situation.
demonstrated doubtful benefit of diuretics in acute
pulmonary edema. Intravenous furosemide ranging References:
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reduction in preload.8
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preeclampsia causing acute postpartum dyspnoea
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which is uncommon.4 In our case, patient developed postpartum admissions to the intensive care
acute pulmonary edema on 4th postoperative day. unit: a systematic review. Intensive Care Med
She had known risk factors that would precipitate (2010) 36:1465–1474. doi:10.1007/s00134-
acute pulmonary edema: severe preeclampsia and 010-1951-0.
anemia. However, the anemia was corrected by
3. Sciscione AC, Ivester T, Largoza M, Manley J,
transfusing two units of packed red cells. she was Shlossman P, Colmorgen GH. Acute pulmonary
given intravenous infusion of oxytocin and edema in pregnancy. Obstet Gynecol
intravenous fluid in the post operative period. 2003;101:511–5.
Oxytocin has been reported to cause water
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intoxication with high accumulative doses (40-50 units
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accumulative doses) in conjunction with large volume
uncommon cause of shortness of breath in a
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