CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 5, September/October 2022 274 AFRICA minute, oxygen saturation was 87% on nasal prong oxygen, which improved to 94% on poly-mask, and she had an oblique foetal lie. Special investigations showed a white cell count of 8.87 × 109 cells/l, haemoglobin of 9.4 g/dl, platelet count of 293 × 109 cells/l, blood urea of 2.3 mmol/l, serum creatinine of 83 µmol/l, alanine transaminase of 7 U/l, aspartate transaminase of 21 U/l, lactate dehydrogenase of 686 U/l and international normalised ratio of 1.2. Arterial blood gas showed a pH of 7.39, potassium of 2.5 mmol/l, glucose of 9.0 mmol/l, lactate of 10.7 mmol/l, oxygen saturation 96.3%, base excess –13.4 and bicarbonate of 14.4 mmol/l. A diagnosis of PE with severe features complicated by hypokalaemia and PulmE was made and the management plan included the need to exclude cardiac pathology. Electrocardiography showed sinus tachycardia. Correction of hypokalaemia with potassium chloride infusion was commenced. She was booked for an emergency caesarean delivery (CD) in maternal interests. Following consultation with the multidisciplinary team, the anaesthetic team led by a specialist anaesthesiologist inserted a central venous pressure (CVP) and arterial line catheters in the maternity ward before the CD. These were inserted for assessment of haemodynamic status8 and administration of intravenous therapies through the CVP catheter. Immediately after insertion of the CVP catheter, the patient became severely dyspnoeic, BP decreased to 84/42 mmHg and she was intubated and transferred to the intensive care unit (ICU) because she was unstable to undergo CD immediately. Notably, the ICU lacked a critical-care subspecialist and the patient’s management therein was under the supervision of non-critical-care specialists. A chest radiograph showed cardiomegaly, prominent upper lobe vessels, interstitial shadowing and right-sided iatrogenic pneumothorax, and a chest tube was inserted (Fig. 1). There was no cardiologist in the tertiary hospital to review the patient. The echocardiography, interpreted by an experienced clinician, showed poor myocardial contractility with ejection fraction < 40%, indicating less need for N-terminal pro b-type natriuretic peptide (NT-proBNP) and BNP assay,9 and peripartum cardiomyopathy was suspected. She received antibiotics and supportive care, including a dobutamine infusion. Computed tomographic pulmonary angiography was requested to exclude pulmonary embolism but the imaging could not be performed because the services were not available at the tertiary hospital. Anticoagulation was considered but the planned CD made it a contra-indication.10 While in ICU, the patient developed cardiac arrest and was resuscitated with chest compression and inotropes. The results of the subsequent laboratory investigations were C-reactive protein 59 mg/l, white cell count 17.04 × 109 cells/l, haemoglobin 10.6 g/dl, haematocrit 0.346, platelet count 144 × 109 cells/l, neutrophils 15.30 × 109 cells/l, blood urea 3.7 mmol/l, serum creatinine 140 µmol/l, alanine transaminase 62 U/l, aspartate transaminase 219 U/l, lactate dehydrogenase 2 253 U/l and total bilirubin 5 µmol/l. Following a 17-hour stay in ICU, she had another cardiac arrest with the foetus in utero and resuscitation failed. Discussion Obstetric issues raised by this case report include lack of antenatal care, non-adherence to referral pathways, the occurrence of hypokalaemia in PE, management of severe PulmE in pregnancy, the role of resuscitative CD and the need for a multi-disciplinary team for the management of critically ill patients. The highlights of the case are shown in Table 1. Factors contributing to the of lack antenatal care are inadequate awareness, acceptability, availability, accessibility and affordability of prenatal services.11 In this case, the patient alleged that she had been unaware of her pregnancy. This calls for improvement in public health education in low- and middleincome countries (LMICs) about the need to visit a healthcare facility when there is a symptom such as amenorrhoea and/or abnormal uterine bleeding. Antenatal care allows identification of women at increased risk of PE12 and to offer them prophylactic aspirin and calcium supplementation for the prevention of hypertensive disorders of pregnancy. There was considerable delay in instituting appropriate emergency care as the patient was referred to a district hospital and then to a tertiary hospital. Referral pathways and advice from specialists or experienced medical officers should be obtained and utilised. Referral indicators and pathways exist in the South African setting,13 but are often not used. Provincial/ state health authorities should ensure that there is constant training on referral indicators and pathways, and any barriers to referrals overcome. Nonetheless, development of PulmE in a pre-eclamptic patient should be considered an indication for a direct referral to a specialist hospital. While the cause of PE is poorly understood, a compendium of theories about the pathogenesis has been reported.14 In a patient with PE, the occurrence of hypokalaemia is possibly due to an abnormality in the Na+/K+ ATPase pump, which causes intracellular potassium uptake.15 Another possible cause Fig. 1. Chest radiographs showing pneumothorax (white arrow) and chest tube (black arrow). Table 1. Highlights of the case Serial no Highlights 1 The occurrence of pulmonary oedema indicates dysfunction in one or many organ systems and interferes with gas exchange causing hypoxaemia and hypercapnia, which may affect other organs, making it difficult to discern the cause-and-effect sequence of events. 2 A diagnosis of pulmonary oedema must be considered in the presence of dyspnoea and pre-eclampsia. 3 Development of pulmonary oedema in a pre-eclamptic patient should be considered an indication for a direct referral to a specialist hospital. 4 The presence of severe hypertension in a patient with pre-eclampsia complicated by pulmonary oedema (particularly in the presence of tachycardia) requires the use of nitroglycerin as an antihypertensive. 5 Pre-eclampsia complicated by pulmonary oedema is an indication for delivery, and this should be expeditiously performed in a hospital with the capacity to offer critical care.
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