Severe Postpartum Hypertension and Acute Heart Failure Exacerbation in a 34-Year-Old African American Woman: Implications for Maternal Mortality and Racial Disparities

Moultrie, GA

Introduction: Postpartum hypertension and cardiomyopathy remain significant contributors to maternal morbidity and mortality in the United States, disproportionately affecting African American women. We present the case of a 34-year-old African American G6P3124 with a history of chronic hypertension and suspected peripartum cardiomyopathy. The patient presented four days postpartum with acute shortness of breath and orthopnea. Pregnancy was complicated by poorly controlled underlying chronic hypertension with worsening dyspnea requiring induction of labor at 36 weeks gestational age (GA) and prior hospitalization for volume overload, dyspnea, and COVID-19 at 33 weeks GA.

Case Description: On presentation, the patient was found to have severe-range blood pressures (207/113 mmHg), tachypnea, and hypoxia, ultimately requiring admission to the ICU. Labs revealed elevated proBNP (>600 pg/mL from < 100 pg/mL previously) and stable troponins; all other labs were essentially normal. Imaging demonstrated bilateral pulmonary infiltrates and pulmonary edema with pleural effusions. Echocardiography showed preserved left ventricular ejection fraction (50–55%). Differential diagnoses included acute heart failure exacerbation in the setting of postpartum cardiomyopathy, postpartum hypertensive emergency, acute exacerbation of underlying hypertension, and postpartum preeclampsia with severe features.

Discussion: Postpartum cardiomyopathy is defined as maternal heart failure with systolic dysfunction and left ventricular ejection fraction (LVEF) less than 45% developing in either the last month of pregnancy or the first five months postpartum in someone without history of pre-existing cardiac dysfunction. This patient’s ECHO from both admissions showed an LVEF of 50-55%, thus not meeting diagnostic criteria.. Postpartum hypertensive emergency is defined as BPs exceeding 240/140 mmHg with evidence of acute end-organ damage. On admission, the patient had severely elevated blood pressures (207/113 mmHg) with a headache that could be considered evidence of end-organ damage, but this is more suggestive of postpartum pre-eclampsia with severe features, defined as new onset hypertension after delivery (>140/90 mmhg) with signs/symptoms including proteinuria, thrombocytopenia, impaired liver function, renal insufficiency, or severe blood pressures (>160/110). While the patient did have proteinuria (512 mg in 24 hour urine collection) and severe range blood pressures, the chronic difficulty in controlling blood pressures throughout pregnancy and then postpartum suggest an acute exacerbation of underlying chronic hypertension rather than new onset preeclampsia. As demonstrated, this case highlights the diagnostic complexity of maternal cardiovascular disease as the patient’s clinical presentation does not clearly align with a single diagnosis.

Outcome: Since the initial admission at 33 weeks, cardiology has been following and guiding management of this patient in both the inpatient and outpatient settings. Her BP has improved with appropriate medication adjustments with lifestyle modifications discussed and encouraged. She was discharged from the ICU after several days of monitoring and cardiac evaluation which revealed no underlying ischemia.

This case highlights the critical importance of vigilant postpartum blood pressure monitoring, early recognition of cardiopulmonary symptoms, and coordinated multidisciplinary care, especially in high-risk populations.