Postpartum Emergencies: Headache, Hypertension, Eclampsia, And Cardiomyopathy

It is Friday evening in the ED, and your first patient is a 42-year-old woman whose chief complaint is headache that began at around 9 AM. She is a gravida 3, para 2–0–1–2 with a history of a previous C-section but no other significant past medical history. On further examination, you establish that 6 days earlier she had a C-section delivery with spinal anesthesia for a 36-week pregnancy because of premature rupture of membranes. Otherwise, this pregnancy and previous pregnancies were uneventful, and mother and baby went home on post-op day 4. Her headache has been severe and continuous for the past 6 hours, unrelieved with ibuprofen taken 3 hours earlier. Pain is now 10/10, and she had 2 episodes of vomiting shortly after her arrival in the ED. There are no visual symptoms, fever, chills, or focal weakness. Her triage blood pressure is 170/85. The ED is busy, and your focus is on throughput, but this patient has a concerning differential diagnosis that includes postdural puncture headache, subarachnoid hemorrhage, and venous sinus thrombosis. You are also concerned about the blood pressure, and though it may be elevated because of her pain, you wonder if you should consider postpartum hypertension.

Later in your shift around 4 AM, a 40-year-old woman is brought in by ambulance with a chief complaint of shortness of breath. The nurse calls you to the bedside because the patient has labored respirations. Her shortness of breath has become more severe over the past 3 days, and she is also complaining of cough and orthopnea. She delivered twins by C-section 2 weeks ago, and the pregnancy was complicated by preeclampsia. She has no significant past medical history. Her blood pressure is 180/120 mm Hg, heart rate 136 beats per minute, respiratory rate 32 breaths per minute, temperature 37.4°C (99.32°F), and pulse oximetry 94% with a 100% nonrebreather mask. On examination, she has jugular venous distention, bibasilar rales, an S3 gallop, and trace pedal edema. The patient clearly appears to have acute pulmonary edema. Your question is, why?