A Case Report

Acute Postpartum Pulmonary Edema in a 34-year-old

Preeclampsia Woman
Yohanes Susanto1, Patrice Ginting2, Ruddy Hardiansyah3

Abstract

Acute dyspnea after pregnancy is a rare presentation and a number of important conditions may accompany it. Pulmonary embolism, amniotic
fluid embolism, pneumonia, aspiration, and pulmonary edema are some of the potential causes that must considered. Pulmonary edema com-
plicates around 0,05% of low-risk pregnancies but may develop in up to 2,9% of pregnancies complicated by preeclampsia, with 70% of cases
occurring after birth. The most common contributing factors include peripartum cardiomyopathy, underlying cardiac disease, preeclampsia,
administration of tocolytic agents and iatrogenic fluid overload. Here we report a case of 34-year-old woman of 1st postpartum day following
lower uterine cesarean section presented with acute progressive dyspnea from her first pregnancy who was admitted in intensive care unit with
history of preeclampsia. Clinical examination and relevant investigations explored that it was a case of acute pulmonary edema. Patient was kept
in ventilator and was treated with intravenous diuretic and calcium channel blocker. After diuresis, considerable improvement was observed in
her respiratory status. The day after, the patient became hemodynamically stable and was weaned off the ventilator. After seven days, she was
discharged in stable condition.

Keywords: post-partum, pulmonary edema, preeclampsia

ABSTRAK
Dispnea akut setelah kehamilan merupakan keadaan yang jarang terjadi serta seringkali disertai kondisi-kondisi penting lainnya. Emboli paru,
emboli air ketuban, pneumonia, aspirasi, dan edema paru, adalah penyebab dispnea yang perlu dipikirkan. Edema paru terjadi pada 0,05% pada
kehamilan dengan risiko rendah, tetapi dapat meningkat menjadi sebesar 2,9% pada kehamilan dengan preeklampsia, dengan 70% terjadi setelah
persalinan. Faktor pendukung lainnya adalah kardiomiopati peripartum, adanya penyakit jantung, preeklampsia, pemberian obat tokolitik, dan
kelebihan pemberian cairan. Berikut ini adalah sebuah kasus pada seorang perempuan berusia 34 tahun post partum 1 hari dengan riwayat sectio
caesarea dan preeklampsia yang mengalami dispnea akut progresif sehingga dirawat di ICU. Pemeriksaan fisik dan pemeriksaan lainnya menun-
jukkan bahwa kasus ini merupakan sebuah kasus edema paru akut. Pasien menggunakan ventilator dan mendapat terapi diuretik intravena serta
penyekat kanal kalsium. Setelah mendapat terapi diuresis, kondsi pasien membaik. Setelah tujuh hari perawatan, pasien dipulangkan dengan
kondisi stabil

Kata kunci: post-partum, edema paru, eklampsia

Introduction Approximately 20 hours later, she presented progressive dyspnea.

She looked pale, unwell and was able to speak only a few words. On
Postpartum pulmonary edema is a rare clinical entity.1 Acute pulmo- physical examination, she had marked respiratory distress and chest
nary edema, which signifies severe disease, is a leading cause of death auscultation revealed basal crackles with reduced breath sounds bilat-
in women with preeclampsia, and the fourth most common form of erally. Peripheral edema was noted. Her oxygen saturation on room air
maternal morbidity. It is also frequently the reason for intensive care 78%, blood pressure was 200/120 mmHg, pulse rate 137 beats/min,
admission, and may occur during antenatal, intrapartum or postpartum respiratory rate was 40 breaths/min and body temperature was normal.
periods.2 Pulmonary edema complicates around 0,05% of low-risk Electrocardiography showed sinus tachycardia and chest radiography
pregnancies but may develop in up to 2,9% of pregnancies compli- revealed cardiomegaly with pulmonary congestion sign (Fig. 1), com-
cated by preeclampsia3-4, with 70% of cases occurring after birth.2-3 patible with acute pulmonary edema.
A clinician needs to be aware of the physiologic changes in the
maternal cardiovascular system that accompany pregnancy predispose
to the development of pulmonary edema, such as increase in plasma Address for Correspondance : dr. Yohanes Susanto
blood volume, cardiac output, heart rate, and capillary permeability
and a decrease in plasma colloid osmotic pressure. Resuscitation is the
Email : yohanessusantomd@gmail.com
foremost priority, followed by formulation of a differential diagnosis
to address the underlying condition.4 Here we report a postpartum
patient who presented with acute pulmonary edema with severe respi-
ratory compromise.
How to cite this article :
Case Illustration
Acute Postpartum Pulmonary Edema
The patient was a 34-year-old primigravida woman with preeclampsia in a 34-year-old
who was admitted to the hospital for delivery by cesarean section. Preeclampsia Woman
Apparently there were no problems with the operative procedure.

IndonesianJournal Chest & Critical Care Medicine Vol.4 No.1 Januari-Maret 2017
introduction oxygen saturation on room air 78%,
Postpartum pulmonary edema blood pressure was 200/120 mmHg,
is a rare clinical entity.1 Acute pulse rate 137 beats/min, respiratory
pulmonary edema, which signifies rate was 40 breaths/min and body
severe disease, is a leading cause of temperature was normal.
death in women with preeclampsia, Electrocardiography showed sinus
and the fourth most common form of tachycardia and chest radiography
maternal morbidity. It is also revealed cardiomegaly with pulmonary
frequently the reason for intensive care congestion sign (Fig. 1), compatible
admission, and may occur during with acute pulmonary edema.
antenatal, intrapartum or postpartum
periods.2 Pulmonary edema
complicates around 0,05% of low-risk
pregnancies but may develop in up to
2,9% of pregnancies complicated by
preeclampsia3-4, with 70% of cases
occurring after birth.2-3 A clinician
needs to be aware of the physiologic
changes in the maternal cardiovascular
system that accompany pregnancy
predispose to the development of
pulmonary edema, such as increase in
plasma blood volume, cardiac output,
heart rate, and capillary permeability
and a decrease in plasma colloid Fig. 1 Chest radiograph showing
osmotic pressure. Resuscitation is the cardiomegaly with pulmonary
foremost priority, followed by congestion sign, compatible
formulation of a differential diagnosis with acute pulmonary edema
to address the underlying condition.4
Here we report a postpartum patient
who presented with acute pulmonary Laboratory data showed mild
edema with severe respiratory leukocytosis (13.600/mm3),
compromise. thrombocytopenia (100.000/mm3),
elevated liver function test (AST 62
case illustration U/L, ALT 35 U/L), elevated renal
The patient was a 34-year-old function test (BUN 29,87 mg/dL,
primigravida woman with creatinine 1,5 mg/dL), and
preeclampsia who was admitted to the hypoalbuminemia (2,3 g/dL). Initial
hospital for delivery by cesarean resuscitative measures included
section. Apparently there were no oxygen administration by non-
problems with the operative procedure. rebreathing mask and intravenous
Approximately 20 hours later, she diuretics were given but clinical
presented progressive dyspnea. She condition of the patient was not
looked pale, unwell and was able to improved. Then she was shifted to ICU
speak only a few words. On physical for respiratory support. The day after,
examination, she had marked her pulmonary edema was significantly
respiratory distress and chest resolved. Oxygen saturation was 98%
auscultation revealed basal crackles on room air and ECG was within
with reduced breath sounds bilaterally. normal limit. She was
Peripheral edema was noted. Her hemodinamically stable and was

IndonesianJournal Chest & Critical Care Medicine Vol.4 No.1 Januari-Maret 2017
weaned off the ventilator. Seven days parameters; however, in one large trial
later she was discharged with and a systematic review, volume
medications which included antibiotic, expansion was not beneficial.
diuretic and anti hypertensive agent Intravenous fluid therapy may also
exacerbate acute respiratory distress
discussion syndrome, leading to hypoxemia, high
airway pressures and difficulty with
The differential diagnosis for ventilation. The postpartum period is
postpartum dyspnea without high-risk for the development of acute
pulmonary edema include pulmonary pulmonary edema. The use of
embolism, amniotic fluid embolism, intravenous fluids to increase plasma
pneumonia, foreign body aspiration volume or treat oliguria, which is
and psychogenic dyspnea. These multifactorial in nature, in a woman
diagnosis were promptly excluded in with normal renal function and stable
this case by history, physical serum creatinine levels, is therefore not
examination, and noninvasive data. recommended. Antenatal fluid therapy
Dyspnea with pulmonary edema may be indicated if there are concerns
includes cardiogenic and non- about placental perfusion; however,
cardiogenic causes. Cardiogenic causes communication with the obstetric team
are peripartum cardiomyopathy, and cautious use should occur, with
preeclampsia related with heart failure, close monitoring of cardiovascular and
underlying cardiac disease (e.g. respiratory function.2
valvulopathy), myocardial ischemia Tocolytic agents, which include
and sepsis with poor cardiac output. terbutaline, ritodrine, salbutamol, and
Non-cardiogenic causes are iatrogenic isoxsuprine, suppress premature
fluid overload, thyroid disease, uterine contractions during pregnancy.
tocolytic therapy or medication-related These B-adrenergic agonists increase
sepsis and acute respiratory distress intracellular cyclic adenosine
syndrome.1,5 monophosphate levels, thus decreasing
Pulmonary embolism would muscular contraction. Pulmonary
not account for diffuse rales, a edema has been reported in association
congested chest x-ray film, high wedge with the short-term use of B-
pressure and diffusely hypokinetic LV adrenergic agonists (average 54 hours)
function on echocardiography. in late pregnancy with an incidence of
Amniotic fluid embolism is a rare but approximately 0 to 4,4%. Pulmonary
potentially fatal outcome of edema occurs during current or recent
pregnancy.6 The classic presentation (<24 hours) usage or appears less than
involves the acute onset of severe 12 hours postpartum when tocolytic
dyspnea, hypoxemia and hypotension, therapy has failed. Unlike pulmonary
followed within minutes by cardiac edema due to congestive heart failure,
arrest. It usually occurs during labor cardiomegaly and pulmonary vascular
and delivery. The patient typically has redistribution are generally absent in
a sudden deterioration in her condition cases that are drug-related.1-2
and may have cardiac arrest.5 Peripartum cardiomyopathy
Iatrogenic fluid overload is (PPCM) is a rare life-threatening
recognized as a significant risk factor cardiomyopathy of unknown cause that
for the development of acute occurs in the peripartum period in
pulmonary edema. Historically, the use previously healthy women. Typically,
of intravenous fluids was though to it can occur in the last month of
improve maternal cardiovascular pregnancy or in the 5 months

IndonesianJournal Chest & Critical Care Medicine Vol.4 No.1 Januari-Maret 2017
following delivery. Common reported severe disease, is a leading cause of
risk factors for PPCM are advanced death in women with preeclampsia,2-4,9
maternal age, multiparity, multiple and the fourth most common form of
gestations, African American race, maternal morbidity.2 It is also
obesity, malnutrition, gestational frequently the reason for intensive care
hypertension, preeclampsia, diabetes, admission.2-3,9
poor prenatal care, breast-feeding, The causes of pulmonary
cesarean delivery, substance and edema are often multifactorial.1-4,10
tobacco abuse, prolonged tocolysis, According to the Starling equation, any
and family history. Symptoms of factor that results in a reduction in
PPCM are identical to those of colloid osmotic pressure (or in the
congestive heart failure and include colloid osmotic pressure/pulmonary
fatigue, paroxysmal nocturnal dyspnea, capillary wedge pressure gradient), an
pulmonary edema, pedal edema, and increased in capillary permeability or
distended neck veins. Symptoms such an increase in intravascular hydrostatic
as fatigue, dyspnea, and edema are pressure will lead to extravasation of
often present in late pregnancy, fluid from the vasculature and
making it difficult to identify patients predispose to the development of
with PPCM.7-8 Additionally, pulmonary edema.3-4
preeclamptic parturients may manifest The underlying physiologic
symptoms of respiratory distress due to changes in the maternal cardiovascular
capillary weak. Ultimately, PPCM system that accompany pregnancy
remains a diagnosis of exclusion. predispose to the development of
Other causes of cardiomyopathy must pulmonary edema. Such changes
be excluded prior to accepting a include an increase in plasma blood
diagnosis of PPCM.7 Because of the volume, cardiac output, heart rate, and
poorly understood nature of this capillary permeability and a decrease
disease, the diagnosis is primarily in plasma colloid osmotic pressure.
established on clinical grounds, and These changes are often exaggerated in
laboratory testing remains basically the setting of preeclampsia, leading to
nonspecific.6 Current diagnosis of a further increase in the incidence of
PPCM is based on the presence of 4 pulmonary edema.4 Labor is associated
clinical criteria: (1) the development of with further increases in cardiac output
cardiac failure within the last month of (15% in the first stage and 50% in the
pregnancy or within 5 months of second stage). Uterine contractions
delivery, (2) the absence of another lead to an auto-transfusion of 300-500
cause to which the cardiac failure can ml of blood back into the circulation
be attributed, (3) no signs or symptoms and the sympathetic response to pain
of heart disease prior to the last month and anxiety further elevate the heart
of pregnancy, and (4) a left ventricle rate and blood pressure. Cardiac output
ejection fraction of less than 45%.1,7-8 is increased between contractions but
Preeclampsia is a multisystem more during contractions. Following
major cardiovascular disease of delivery there is an immediate rise in
pregnancy with hypertension as its cardiac output due to relief of the
main clinical manifestation.2-3 inferior vena cava obstruction and
Pulmonary edema complicates around contraction of the uterus, which
0,05% of low-risk pregnancies but may empties blood into the systemic
develop in up to 2,9% of pregnancies circulation. Cardiac output increases
complicated by preeclampsia.3-4 Acute by 60-80% followed by a rapid decline
pulmonary edema, which signifies to pre-labor values within about one

IndonesianJournal Chest & Critical Care Medicine Vol.4 No.1 Januari-Maret 2017
hour of delivery. Transfer of fluid from differentiating a low cardiac output
the extravascular space increases from a high cardiac output state, as
venous return and stroke volume well as exclude other important causes
further. Those women with of acute pulmonary edema.2-3
cardiovascular compromise are Despite the risks of aspiration,
therefore most at risk of pulmonary non-invasive ventilation should be
edema during the second stage of labor tried as the initial technique before
and the immediate postpartum period. tracheal intubation, as it provides
Cardiac output has nearly returned to increased inspired oxygen
normal (pre-pregnancy values) two concentration, displaces fluid from the
weeks after delivery, although some alveoli into the pulmonary and
pathological changes (e.g. subsequently systemic circulation,
hypertension in preeclampsia) may decreases the work of breathing, and
take much longer.11 Moreover, in decreased the need for tracheal
normal pregnancy, plasma colloid intubation. The use of non-invasive
osmotic pressure decreases from ventilation also avoid the
around 22 mmHg at term to 16 mmHg complications associated with tracheal
after delivery (and from 18 mmHg at intubation in pregnant or recently
term to 14 mmHg postpartum in pregnant women who are hypertensive,
pregnancies complicated by such as intracerebral haemorrhage.
preeclampsia). The reduction in colloid Mechanical ventilation strategies
osmotic pressure after delivery may incorporating the known
result from excessive blood loss, fluid cardiorespiratory and metabolic
shifts secondary to increased capillary changes of pregnancy need to be
permeability (especially in considered when ventilating the lung
preeclamptic pregnancies), or of a pregnant or recently pregnant
excessive crystalloid infusion. Such woman, as well as the lung protective
changes help to explain at least in part strategies of low tidal volumes and low
why 70-80% of pulmonary edema in peak pressures. Avoidance of
the setting of preeclampsia develop aortocaval compression is essential.2-3
after delivery.4 An additional feature Urgent reduction of critically
that may predispose to the high blood pressure with an
development of pulmonary edema in intravenous antihypertensive agent is
the setting of preeclampsia is an necessary. Nitroglycerin (glyceryl
increase in capillary leak and capillary trinitrate) is recommended as the drug
fluid extravasation secondary to of choice in preeclampsia associated
vascular endothelial damage.3-4 with pulmonary edema. An alternative
The occurrence of acute agent, sodium nitroprusside, is
pulmonary edema in a hypertensive recommended in severe heart failure
pregnant or recently pregnant woman and critical hypertension; however it
is a medical emergency and should should be used only with caution and
trigger an emergency response aimed by experienced clinicians. Intravenous
at rapidly assembling an experienced furosemide is used to promote
team of staff. Further deterioration venodilation and diuresis. If
may occur, leading to cardiac arrest, hypertension persists depite the
and staff should be prepared to combination of nitroglycerin or sodium
institute advanced life support and nitroprusside and furosemide, then a
consider peri-mortem caesarean calcium channel antagonist such as
section. Transthoracic nicardipine or nifedipine may be
echocardiography can assist in considered. Prazosin as well as

IndonesianJournal Chest & Critical Care Medicine Vol.4 No.1 Januari-Maret 2017
hydralazine may also be considered; recently given birth is an uncommon
however, reflex tachycardia may be clinical scenario with some life-
deleterious in this setting. Intravenous threatening complications. A
morphine may also be given as a multidisciplinary team that includes
venodilator and anxiolytic. High anesthesia provider, obstetricians,
dependency care and close observation internist, cardiologist and critical care
are essential.2-3 specialists will be needed to help aid in
Women who suffer from the diagnosis and management. No
preeclampsia and experience acute matter what the underlying pathology,
pulmonary edema are at increased risk prompt appropriate resuscitation is
of cardiovascular complications in always the first priority.
later life, including hypertension,
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