Timeline of clinical events.
| Event | Details/Findings |
|---|---|
| Previous pregnancy three years prior | Diagnosed with pulmonary hypertension during her fourth pregnancy and underwent an emergency cesarean section. Transthoracic echocardiography (TTE) revealed a large secundum atrial septal defect (ASD) and severe pulmonary hypertension with a right ventricular systolic pressure (RVSP) of 94 mmHg. |
| Two weeks prior to hospital admission | Presented to an outside hospital for shortness of breath and palpitations. TTE RVSP was 105 mmHg. |
| Admission to labor and delivery service | Presented at 37 weeks gestation with worsening dyspnea, dizziness, and pre-syncopal episodes with exertion. |
| Placement of epidural catheter | After activation of the epidural, she developed hypotension requiring vasopressor support and eventual discontinuation of the epidural. |
| Transfer to the intensive care unit (ICU) | On vasopressor support and inhaled nitric oxide. TTE showed a 2.4 cm ostium secundum ASD with intermittent right-to-left shunting, RVSP 80 mmHg with systemic systolic pressure of 95 mmHg. A radial arterial and central venous catheter were placed. |
| Cesarean section delivery | Epidural incrementally loaded in the operating room. Extracorporeal cardiopulmonary resuscitation (ECPR) catheters were placed. Required vasopressin, phenylephrine, and epinephrine infusions. Her baby was delivered by cesarean section. |
| Post-operative day one | Remained on inhaled nitric oxide, a vasopressin infusion, and treprostinil. |
| Post-operative day eleven | Weaned off vasoactive support. Treprostinil was continued and she was started on goal directed therapy with tadalafil, furosemide, and spironolactone. Discharged on postoperative day 11 with supplemental oxygen (2–4 L/min via nasal cannula). |
| Six weeks after discharge | Readmitted six weeks after discharge with a pulmonary hypertensive crisis, ventricular fibrillation arrest, and acute hypoxic respiratory failure. |
| Nine months after discharge | She unfortunately passed away 9 months later due to an out of hospital cardiac arrest. |