Pulmonary edema associated with pregnancy: echocardiographic insights and implications for treatment

To evaluate the role of echocardiography in determining the cause of pulmonary edema in pregnancy and the impact this information has on management.

We studied prospectively 45 pregnant or recently postpartum women admitted to an obstetric intensive care unit with pulmonary edema during a 6-year period. Between 1 and 4 days after the onset of pulmonary edema, two-dimensional and M-mode echocardiography was performed, as was continuous, pulsed, and color Doppler echocardiography. The clinical diagnosis obtained from history, physical examination, chest radiograph, and laboratory data was compared with the echocardiographic diagnosis.

Three therapeutically and prognostically distinct groups were identified by echocardiography: 1) those with decreased systolic function (N = 19), 2) those with normal systolic function but increased left ventricular mass and presumed diastolic dysfunction (N = 17), and 3) those with normal hearts (N = 9). During the study period, two patients with systolic dysfunction died and one underwent cardiac transplantation. Patients with systolic dysfunction required short- and long-term treatment with digoxin, diuretics, and angiotensin-converting enzyme inhibitors. Those with diastolic dysfunction received diuretics and long-term antihypertensive therapy. Women with normal hearts required acute therapy only. In 21 patients (47%), echocardiography demonstrated clinically unsuspected findings, which altered the long-term management in 16.

Because clinical and roentgenographic findings do not accurately differentiate patients with respect to the presence and type of cardiac dysfunction, and because these subgroups differ with respect to treatment and probably prognosis, we recommend echocardiography to evaluate all pregnant women with pulmonary edema.