What is the best next step in managing a pregnant woman at 38 weeks gestation with dyspnea, mild hypertension, tachycardia, and a new holosystolic murmur?

From the Guidelines

The best next step in management for this 34-year-old woman at 38 weeks gestation with new-onset shortness of breath, tachycardia, a new holosystolic murmur, and lower extremity edema is an urgent echocardiogram. This patient is presenting with signs and symptoms highly suggestive of peripartum cardiomyopathy, a rare but serious cardiac condition that occurs in late pregnancy or the early postpartum period. The presence of an S3 gallop, new holosystolic murmur (likely mitral regurgitation), tachycardia, and peripheral edema all point toward heart failure. While her request for delivery is understandable given her discomfort, the priority must be to assess cardiac function before proceeding with delivery planning. An echocardiogram will evaluate left ventricular function, ejection fraction, and any valvular abnormalities. If peripartum cardiomyopathy is confirmed, management would include a multidisciplinary approach involving cardiology and high-risk obstetrics, with potential treatments including diuretics, beta-blockers, and careful planning of delivery to minimize cardiac stress, as outlined in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. Immediate delivery without cardiac evaluation could potentially worsen her condition and increase risks to both mother and baby.

Some key considerations in the management of this patient include:

• Close maternal monitoring for heart failure signs or symptoms or other cardiovascular instability by cardiology and obstetric and maternal-fetal medicine teams
• Consideration of routine echocardiographic screening in the third trimester for reassessment of myocardial structure and function before labor
• BNP or NT-proBNP monitoring during pregnancy may have some value for prediction of cardiovascular events
• Multidisciplinary management with obstetrics and maternal-fetal medicine teams during pregnancy, and potential involvement of other specialties such as neonatology and pediatrics in the postpartum period.

It's also important to note that the patient's blood pressure is 132/85 mm Hg, which is not indicative of hypertensive emergency, and therefore does not require immediate blood pressure reduction with intravenous medications such as labetalol or oral nifedipine, as suggested in the European Society of Cardiology position paper on peripartum management of hypertension 1. However, close monitoring of blood pressure and other vital signs is still essential in this patient.

Overall, the priority in this patient's management should be to assess and stabilize her cardiac function, rather than proceeding with immediate delivery, in order to minimize risks to both mother and baby.

From the Research

Patient Assessment

The patient is a 34-year-old woman, gravida 1 para 0, at 38 weeks gestation, presenting with increasing shortness of breath and discomfort due to pregnancy. She has no significant medical conditions and does not use tobacco or alcohol. Her blood pressure is 132/85 mm Hg, pulse is 112/min and regular, and an S3 is present on cardiac auscultation. A new grade III/VI holosystolic murmur is heard at the apex, and pitting edema is present over the lower extremities.

Clinical Findings

• The patient's symptoms and physical examination findings suggest heart failure, which is a complication that can occur during pregnancy 2, 3, 4.
• The presence of an S3 heart sound and a holosystolic murmur indicates ventricular volume overload and potential mitral regurgitation, respectively.
• Pitting edema and shortness of breath are consistent with fluid overload and congestive heart failure.

Management Options

• Diuretic therapy is a mainstay in the management of heart failure, and loop diuretics such as furosemide are commonly used to relieve congestive symptoms 2, 3, 5.
• Early administration of furosemide has been associated with improved oxygenation in patients with acute heart failure 4.
• However, diuretic therapy should be used cautiously in pregnant women, as it can affect fetal well-being and maternal hemodynamics.

Next Steps

• The best next step in management would be to consult with a cardiologist and obstetrician to determine the optimal approach for this patient's care.
• Consideration should be given to the use of diuretics, such as furosemide, to relieve congestive symptoms, while closely monitoring the patient's hemodynamics and fetal well-being 2, 3, 4, 5.