Endgames Case Report

Postpartum fever and shortness of breath

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f391 (Published 24 January 2013) Cite this as: BMJ 2013;346:f391
  1. Adam Morton, staff specialist, obstetric medicine and endocrinology
  1. 1QLD Diabetes Centre, Mater Hospital, Raymond Tce, South Brisbane, Australia 4101
  1. Correspondence to: A Morton adam.morton{at}mater.org.au

A 26 year old gravida 3 para 2 woman developed fever and malaise after an uncomplicated spontaneous vaginal delivery at 38 weeks’ gestation. Postpartum vaginal loss was unremarkable. Her baby, a boy with a birth weight of 3420 g, was well. Her symptoms were initially attributed to a viral illness. However, she gradually became more unwell over the next two days with lightheadedness, abdominal pain, fever, and shortness of breath, and she was noted to have tachycardia and hypotension. On the third day postpartum, while still an inpatient, she was extremely unwell. Pulse rate was 140 beats/min, blood pressure was 80/20 mm Hg, and oxygen saturations were 91% while breathing oxygen at 6 L/min. Heart sounds were dual, chest examination showed bibasal crackles, and she had hypogastric tenderness. Initial investigations were haemoglobin 96 g/L (pregnancy specific reference range 115-165), white blood cell count 11.2×109/L (4-15), platelets 155×109/L (150-400), prothrombin time 21 s (11-16), activated partial thromboplastin time 52.7 s (23-38), fibrinogen 13.2 µmol/L (5.1-11.8; 1µmol/L=3401 mg/dL), creatinine 136 µmol/L (1 µmol/L=0.01 mg/dL;30-70), estimated glomerular filtration rate 41 mL/min (80-120), serum bicarbonate 10 mmol/L (1 mmol/L=1 mEq/L; 22-33), and venous lactate 6.6 mmol/L (1 mmol/L=9.01 mg/dL; 0.5-2.2).

She was given intravenous antibiotics and hydrocortisone and transferred to the intensive care unit (ICU). Chest radiography showed diffuse bilateral lower zone infiltrates. A non-contrast computed tomogram of the abdomen and pelvis was unremarkable. Echocardiography showed bilateral reduction in left and right ventricular function, with a left ventricular ejection fraction (LVEF) of 40% and no evidence of endocarditis. Cardiac troponin I was raised at 0.34 µg/L (<0.05), with a subsequent peak value of 22 µg/L.

Questions

  • 1 What is the most likely cause of the patient’s initial deterioration?

  • 2 What were the possible factors in her cardiac dysfunction?

  • 3 What are …

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