CHEST Guidelines-A-Pregnant-Woman-in-the-Third-Trimester-Diagnosed-

A-Pregnant-Woman-in-the-Third-Trimester-Diagnosed-

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A 33-year-old pregnant woman at 34 weeks of gestation was admitted to the ICU with symptoms of acute respiratory failure and severe lower-extremity edema. The patient, who had a history of methamphetamine abuse but a previously uncomplicated pregnancy, exhibited low oxygen saturation, increased heart rate, decreased blood pressure, and symptoms indicative of right ventricular overload, including jugular venous distention and muffled heart sounds. Initial evaluations considered pulmonary embolism (PE) and idiopathic pulmonary hypertension due to past methamphetamine use as potential diagnoses, but definitive imaging was challenging due to the patient's pregnancy and critical condition.<br /><br />Transthoracic echocardiography (TTE) indicated severe right ventricular and atrial dilation and pressure overload. Further investigation with transesophageal echocardiography (TEE) during a cesarean section revealed a large secundum atrial septal defect (ASD) with bidirectional shunting, a condition contributing to cardiac overload and acute hypoxemia. The multidisciplinary team administered IV epoprostenol and dobutamine, and successfully delivered the baby via cesarean section. Following the procedure, the patient was stabilized and provided with medications to manage pulmonary hypertension and was evaluated for potential ASD closure.<br /><br />This case underscores the diagnostic limitations of TTE versus TEE in detecting ASD, especially when complicated by pregnancy-related anatomical changes. It also highlights the risk of exacerbated right-sided heart failure due to shunting in ASD patients under critical conditions like pregnancy, emphasizing the need for multidisciplinary management. The patient was discharged with plans for ongoing care by the pulmonary hypertension team, illustrating the critical need for early and accurate diagnosis and tailored management strategies in similar cases.

Keywords

pregnancy

acute respiratory failure

right ventricular overload

atrial septal defect

pulmonary hypertension

multidisciplinary management

transthoracic echocardiography

transesophageal echocardiography

methamphetamine abuse

cesarean section