A 33-year-old primigravida at 38 weeks gestation presents to the obstetric triage unit wit… — USMLE Step 2 CK

A $33$ -year-old primigravida at $38$ weeks gestation presents to the obstetric triage unit with a $2$ -week history of worsening fatigue, exertional dyspnea, and a persistent dry, nocturnal cough. The patient states she has recently started sleeping in a recliner chair because she feels "smothered" when lying flat in bed. Her pregnancy has been largely uncomplicated, with normal prenatal anatomy scans and glucose tolerance testing. She takes a daily prenatal vitamin. Temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $138/86\text{ mm Hg}$ , pulse is $112/\text{min}$ , and respirations are $22/\text{min}$ . Pulse oximetry is $94\%$ on room air. Physical examination reveals jugular venous distention $8\text{ cm}$ above the sternal angle when sitting at $45$ degrees. Cardiac auscultation demonstrates a regular tachycardia and a low-frequency, early diastolic sound heard best at the apex in the left lateral decubitus position. Lung auscultation reveals fine bibasilar crackles. Bilateral $2+$ pitting pedal edema is present. Fetal heart rate monitoring shows a baseline of $145/\text{min}$ with moderate variability and positive accelerations. Which of the following is the most appropriate next step in the management of this patient?

A
Administration of intravenous ceftriaxone and azithromycin
B
Administration of nebulized albuterol and oral prednisone
C
Immediate emergency cesarean delivery
D
Reassurance and recommendation to sleep in the left lateral decubitus position
Transthoracic echocardiographyCevap

Cevap

Transthoracic echocardiography

The correct answer is transthoracic echocardiography. This patient's presentation is classic for peripartum cardiomyopathy (PPCM), a rare but life-threatening cause of dilated cardiomyopathy that typically presents in the last month of pregnancy or within five months postpartum. While lower extremity edema and mild dyspnea are normal in late pregnancy due to plasma volume expansion and gravid uterine compression of the inferior vena cava, findings such as orthopnea, paroxysmal nocturnal dyspnea, jugular venous distention, and an S3 gallop are unequivocally pathologic. Echocardiography is the definitive non-invasive initial diagnostic test. It is required to establish the diagnosis, which is defined by a left ventricular ejection fraction (LVEF)

< 45\%

, and to evaluate for other potential etiologies such as occult valvular disease.

Adım Adım Çözüm

Analyze the patient's symptoms and timing.

The patient is in late pregnancy (

38

weeks) and presents with new-onset orthopnea, nocturnal cough, and progressive exertional dyspnea.

Timing and symptom clustering help distinguish between isolated respiratory issues, normal pregnancy changes, and systemic disease.

Evaluate the physical examination findings.

The exam reveals elevated jugular venous pressure, an S3 gallop (low-frequency early diastolic sound), bibasilar crackles, and pitting edema.

These findings definitively point to left and right-sided volume overload and ventricular dysfunction (heart failure).

Differentiate pathologic findings from normal physiologic changes of pregnancy.

While pedal edema and mild dyspnea can be physiologic in pregnancy, JVD, an S3 gallop, and orthopnea are always pathologic and indicate a primary cardiac etiology.

Misattributing pathologic signs to normal pregnancy delays life-saving interventions.

Determine the required diagnostic workup.

The clinical picture strongly suggests peripartum cardiomyopathy (PPCM). Transthoracic echocardiography is required to measure left ventricular ejection fraction (LVEF).

A formal diagnosis of PPCM requires echocardiographic evidence of LVEF

< 45\%

in the absence of another identifiable cause of heart failure.

Anahtar Kavram

Diagnosis of Peripartum Cardiomyopathy

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