A 26-year-old woman, G1P0 at 16 weeks gestation, is brought to the emergency department with a 4-day history of progressively worsening shortness of breath, orthopnea, and severe bilateral leg swelling. She has a 4-year history of systemic lupus erythematosus (SLE) but stopped taking hydroxychloroquine and azathioprine 6 months ago because she wanted a "natural pregnancy." Her temperature is 37.6°C (99.7°F), blood pressure is 165/105 mmHg, pulse is 112/min, and respirations are 28/min. Pulse oximetry shows 89% on room air. Physical examination reveals prominent jugular venous distention. Lung auscultation demonstrates bilateral bibasilar crackles and scattered expiratory wheezes. Cardiac examination shows an S3 gallop. There is 3+ pitting edema extending to the mid-thighs.
Laboratory results are as follows:
| Test | Result |
|---|---|
| Hemoglobin | 9.2 g/dL |
| Platelets | 110,000/mm³ |
| Blood urea nitrogen | 58 mg/dL |
| Serum creatinine | 2.8 mg/dL (baseline 0.7 mg/dL) |
| Anti-dsDNA antibodies | Markedly elevated |
| Complement C3 | 35 mg/dL (normal: 80-160) |
| Complement C4 | 8 mg/dL (normal: 15-45) |
Arterial blood gas on room air:
pH: 7.30
pCO₂: 30 mmHg
pO₂: 60 mmHg
HCO₃⁻: 14 mEq/L
Urinalysis shows 4+ protein, numerous red blood cells, and red blood cell casts. Sputum Gram stain reveals rare epithelial cells and no organisms. Chest radiograph with abdominal shielding demonstrates bilateral diffuse alveolar opacities and prominent pulmonary vasculature.
Which of the following is the most appropriate next step in the management of this patient's acute respiratory distress?
- Intravenous furosemide and methylprednisoloneCevap
- BInhaled albuterol and ipratropium
- CIntravenous ceftriaxone and azithromycin
- DEndotracheal intubation and mechanical ventilation
- EReassurance and lower extremity elevation