Diagnostic quagmires to miraculous resolutions: pulmonary hypertension in pregnancy

The study presents a second gravida in her middle age at 25 weeks and 2-day period of gestation with progressive dyspnoea even at rest (New York Heart Association Class IV), palpitations of 3 months, tachycardia, tachypnoea, pallor, clubbing, elevated jugular venous pressure and SpO2 of 80-90%. ECG revealed sinus tachycardia, right ventricular strain and right bundle-branch block. Echocardiography highlighted increased right pulmonary arterial pressures (pulmonary artery pressure of 60/30/42 mm Hg, pulmonary capillary wedge pressure of 30 mm Hg), a dilated right ventricle and elevated right ventricular systolic pressure. A chest X-ray identified bronchiectasis changes. Despite maintaining oxygen saturation through a high-flow nasal cannula (FiO2, 30%), the patient experienced persistent tachypnoea and required oxygen (FiO2, 70%). The ongoing cardiac and pulmonary evaluation did not reveal any autoimmune, hormonal or infective causes of bronchiectasis or pulmonary hypertension.Given the worsening condition, a caesarean section was performed at 32 weeks gestation in a semirecumbent position under epidural anaesthesia with transversus abdominis plane block and she delivered a live preterm neonate. The postoperative phase was managed with inotropes and high-flow nasal oxygen with gradual weaning off of oxygen over 12 weeks.The patient's complex presentation highlights the importance of management of a high-risk case of pulmonary hypertension while continuing a pregnancy with integrated care by addressing severe cardiovascular and pulmonary issues.