What's Wrong With Mom's Heart? A Pregnant Patient With History of HTN and T2DM Presents With Respiratory Distress | Patient Case Quiz

A 44-year-old G4, P3 patient who is 36-weeks pregnant and has a past medical history of hypertension and type-II diabetes is brought in by ambulance for respiratory distress. Initial O2 saturation was 60% and continuous positive airway pressure was started in the field, with an improvement in her O2 saturation to 82%. Upon arrival to the emergency room, she was intubated for respiratory distress and transferred to the intensive care unit.

On arrival, her temperature was 98.9°F, heart rate was 140, blood pressure was 180/90 mm Hg, and intubated O2 saturation was 100% on an FiO2 of 100%. Her exam was notable for an elevated jugular venous pressure to 18 cm H20, a prominent S3 gallop, bilateral pulmonary crackles, and 2+ lower extremity edema. Electocardiogram revealed sinus tachycardia at a rate of 140 with nonspecific ST and T wave abnormalities but no evidence of acute ischemia. Her creatinine was 0.84mg/dL, glucose was 254 mg/dL, lactate was 1.2 mmol/L, liver function tests were normal and her N-terminal B-type natriuretic peptide (NT-BNP) was elevated at 3000 pg/mL. Her initial troponin T was <0.01 pg/mL but rose over the next 24 hours to a peak of 0.29pg/mL. Thyroid stimulating hormone (TSH) was normal at 2.95 uU/mL. Complete blood count and coagulation tests were normal. D-Dimer was elevated at 2871ng/mL. Urinalysis was notable for the absence of protein. Chest X-ray revealed diffuse, bilateral, hazy opacities consistent with pulmonary edema. A bedside echocardiogram revealed a dilated left ventricle with an ejection fraction of 23% and right ventricular dyfunction. Two months prior to presentation, the patient had undergone an echocardiogram at another institution for progressive shortness of breath that documented an ejection fraction of 55%. Notably, the patient's pregnancy had been normal to date. She did not have a history of IVF assistance or pre-eclampsia.

She received 10 mg of IV labetolol for her elevated heart rate and blood pressure, and her blood pressure fell precipitously to the 80s/doppler. Fetal bradycardia was appreciated, and an emergent c-section was performed. The patient was supported with epinephrine, neosynephrine, and phenylephrine during the surgery.

After surgery, she was weaned from pressors and extubated. She was aggressively diuresed, her creatinine rose to 1.44mg/dL, but her urine output remained excellent, and her creatinine subsequently normalized. She was started on a beta-blocker and angiotensin-converting enzyme inhibitor (ACEI). A repeat transthoracic echocardiogram was obtained one week later, showing an ejection fraction of 28%, no left ventricular thrombus, and normalization of her right ventricular function. Her blood pressure remained difficult to control, so hydralazine and nitrates were added to her regimen. She was never started on and aldosterone antagonist. She was discharged home with a plan for a cardiac MRI in two weeks.

Which of the following is the most likely etiology of the patient's presentation?

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