Think of the Children: Pericarditis in Pregnancy

A 27-year-old female with a past medical history significant for pericarditis presents to clinic to establish care for ongoing pericarditis management. She is 8 weeks pregnant, and continues to have symptoms. She was first diagnosed with pericarditis 3 months prior. She initially presented with persistent sharp substernal chest pain, made worse with inspiration. Physical exam with pericardial rub and Ewart's signs present. ECG with mild PR depressions (Figure 1), and echocardiogram with moderate circumferential pericardial effusion (Figure 2). She was initially started on ibuprofen 600mg three times daily, with moderate improvement in symptoms. Ibuprofen was subsequently increased to 600mg four times daily at a recent emergency department visit, given persistent symptoms. On presentation today, she continues to have sharp chest pain, worse with inspiration and lying flat. Vitals today show that she is afebrile, with heart rate of 89 beats per minute and blood pressure of 124/66 mmHg. Echocardiogram today shows largely resolved pericardial effusion. However, patient continues to have elevated inflammatory biomarkers. Ultrasensensitive C-Reactive Protein was 66.2 mg/L on initial presentation, and is 79.9 mg/L today. Westergren erythrocyte sedimentation rate was 42 mm/hr on initial presentation, and is 78 mm/hr today. She was recently seen by an obstetrician and told she is 8 weeks pregnant.

Figure 1: Arrows point to PR depressions

Figure 1

Figure 2: Transthoracic echocardiogram (left: parasternal long axis; right: parasternal short axis)

Figure 2

Which of the following is the best next step for managing this patient's pericarditis?

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