Internal Medicine Resident IMSS san luis potosi, San Luis Potosi, Mexico
Background: During pregnancy, hemodynamic changes increase cardiovascular risk in cases of severe infections. Severe viral pneumonia can lead to pulmonary hypertension, right ventricular (RV) failure, and respiratory distress, with high mortality. Recent studies report that 31% of patients hospitalized for pneumonia develop heart failure within 90 days to 5 years (1-3)
Methods: Comprehensive management was performed, including advanced monitoring in the ICU, portable echocardiography, mechanical ventilatory support, and hemodynamic therapy with inodilators (levosimendan). Imaging studies (Angio-CT, chest CT) and laboratory analyses were conducted to confirm the diagnosis and rule out complications.
Outcome: 20-year-old woman with no relevant medical history was admitted to our labor shock unit with a week-long history of resting dyspnea and general malaise. Initial screening revealed mild urinary sepsis and a 20-week gestation pregnancy. Due to limited response to conservative management, mechanical ventilation and central venous catheter placement were initiated. In the ICU, portable echocardiography revealed a normal-sized left ventricle (LV) and a dilated RV, with a left ventricular ejection fraction (LVEF) of 62%, RV systolic pressure of 49 mmHg, TAPSE of 1.6 cm, and NT-proBNP levels of 35,000. Pulmonary embolism was ruled out through normal D-dimer levels and Angio-CT findings. Chest CT showed bilateral pleural effusion, diffuse infiltrates, and ground-glass opacity. Viral panel testing confirmed rhinovirus/enterovirus infection. Hemodynamic support with levosimendan was initiated for respiratory distress syndrome associated with acute respiratory infection, following low tidal volume ventilation guidelines. A follow-up echocardiogram after 48 hours showed improvement with preservation of maternal-fetal outcomes, with LVEF of 56%, no LV diastolic dysfunction, pulmonary arterial systolic pressure (PASP) of 38 mmHg, RV of 34 mm, and TAPSE of 2.5 cm. Due to improvement, the patient was successfully extubated and after 15 days the patient was discharged without neurological, respiratory, or hemodynamic sequelae.
Conclusion: Hemodynamic changes during second trimester, predispose to cardiovascular complications in severe infections. RV hyperfunction may act as a compensatory response to increased right heart afterload. Elevated NT-proBNP levels confirm myocardial stress. Cardiorespiratory support, and inodilators, improved, RV function. This case highlights the clinical success of comprehensive management in obstetric patients.
