Sir, We would like to report the case of a 37-year-old patient with an undiagnosed heart defect, admitted to the Intensive Care Unit (ICU) with acute respiratory failure and suspicion of pulmonary embolism (PE) after a caesarean section performed one day earlier, in the 34 th week of her 4 th pregnancy. Eventually, the diagnosis of isolated drainage of the right superior vena cava (RSVC) to the left atrium (LA) was made.Our patient had a history of two caesarean sections, one miscarriage, gestational diabetes, pregnancy-induced hypertension, obesity and erythrocythaemia. Initially, the patient was sent to the Obstetrics Department by her general practitioner because of a deterioration in her blood pressure (BP) control. On admission, the patient additionally presented upper respiratory tract infection (URTI) symptoms (voice hoarseness for a week and 2-day history of low-grade fever), dyspnoea on effort and peripheral oedema (ankles and feet). BP on admission was 160/100 mm Hg, Hb 17.1 g dL -1 , Ht 50%, RBC 5.4 T L -1 , PLT 108 G L -1 , WBC 11.9 G L -1 , fibrinogen 2.6 g L -1 . Urea, creatinine, Na, K, aPPT, PT, AST, ALT, ALP, uric acid and bilirubin levels were within normal ranges. The results of arterial blood gas analysis (ABG) were as follows: paO 2 52 mm Hg, paCO 2 30 mm Hg, sO 2 87%, BE -3.1 mmol L -1 . Other parameters were normal. In urinanalysis, bacteriuria, significant leucocyturia and proteinuria (9.68 g L -1 ) were discovered. A chest ultrasound showed nothing significant. During a spirometry, only PEF was below the normal value. The patient was treated with cefuroxime, betamethasone (to stimulate foetal respiratory system maturation), magnesium sulphate, diazepam, inhaled budesonide and supplemental oxygen. As after 4 days her condition had not improved, she was sent to University Gynaecology and Obstetrics Hospital with suspected preeclampsia and PE. In laboratory tests on admission, CBC and coagulogram did not change significantly, there was no troponin elevation, while procalcitonin was 0.17 ng mL -1 , and d-dimmer 731 ng mL -1 (the highest value was 1124 ng mL -1 -two days after admission). A chest X-ray showed opacities in right lower pulmonary region. She was treated with magnesium sulphate, methyldopa, nitrendipine, metoprolol, a subtherapeutical dose of enoxaparin and continued cefuroxime. In the 2 nd day of hospitalization dyspnoea, tachypnoea, retrosternal chest pain and numbness of the upper extremities were observed. BP was 170/110 mm Hg, SpO 2 90% with supplemental oxygen, paO 2 60 mm Hg, paCO 2 33 mm Hg. Markers of myocardial necrosis were at normal ranges. Although the next day her symptoms had improved, lower abdominal pain and vaginal bleeding occurred. An urgent caesarean delivery under general anaesthesia was performed. Intraoperatively, abruption of 25% of the placental surface was discovered. A hypotrophic female infant with an Apgar score of 8 in the 1 st minute and 10 in the 5 th minute was delivered. Evaluated blood loss was 500 mL. Although after the surgery the patient was...
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