A 33-year-old woman delivers a healthy neonate at 38 weeks gestation. Two days later, the mother collapses in the nursery. Examination of medical records shows that the patient's father died at age 45 due to complications of Marfan syndrome. Blood pressure is 110/50 mmHg and pulses are diminished, Cardiac auscultation reveals a diastolic murmur. Which of the following is the most likely diagnosis?
Acute myocardial infarction
Amniotic fluid embolism
Dissecting aortic aneurysm
Pulmonary thromboembolism
Ruptured berry aneurysm
The Correct Answer is C
A. Acute myocardial infarction: Acute myocardial infarction can present with sudden collapse and hypotension, but it is uncommon in a young postpartum woman without significant coronary risk factors. The diastolic murmur and diminished pulses are not typical features of an MI.
B. Amniotic fluid embolism: Amniotic fluid embolism usually occurs during labor or immediately postpartum, presenting with sudden respiratory distress, hypotension, and coagulopathy. Collapse two days postpartum with a diastolic murmur and diminished pulses is less consistent with this condition.
C. Dissecting aortic aneurysm: Aortic dissection is suggested by sudden collapse, hypotension, diminished peripheral pulses, and a diastolic murmur of aortic regurgitation. A family history of early Marfan syndrome increases risk due to connective tissue weakness, making acute aortic dissection the most likely diagnosis in this postpartum patient.
D. Pulmonary thromboembolism: Pulmonary embolism can cause sudden collapse and dyspnea postpartum, but it rarely produces a diastolic murmur or diminished peripheral pulses. The presence of these cardiovascular signs points toward aortic pathology rather than pulmonary embolism.
E. Ruptured berry aneurysm: Ruptured cerebral aneurysms typically present with sudden severe headache, loss of consciousness, or neurological deficits. They do not explain the diastolic murmur or diminished pulses in the context of this patient’s cardiovascular collapse.
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Related Questions
Correct Answer is D
Explanation
A. Bacterial endocarditis:Bacterial endocarditis can produce septic emboli, but it usually presents with systemic signs of infection such as fever, positive blood cultures, and a heart murmur. In this patient, the absence of infection and negative blood cultures make endocarditis less likely.
B. Cardiogenic shock:Cardiogenic shock results in global tissue hypoperfusion, affecting multiple organs simultaneously. Isolated gangrene of a single toe without systemic hypotension does not fit this presentation.
C. Congestive heart failure:Heart failure can cause chronic peripheral edema and poor perfusion, but it rarely leads to acute, localized gangrene in a single distal extremity without other systemic signs.
D. Embolism from mural thrombus:After myocardial infarction, areas of akinetic or dyskinetic myocardium can form mural thrombi in the left ventricle. Small thromboemboli can detach and travel to peripheral arteries, causing acute ischemia and necrosis in distal extremities, such as a toe. This mechanism explains isolated gangrene without systemic hypotension or infection.
E. Hypovolemic shock:Hypovolemic shock produces generalized hypoperfusion and hypotension, typically affecting multiple organ systems. Localized gangrene in a single toe without systemic compromise is inconsistent with hypovolemic shock.
Correct Answer is C
Explanation
A. Fat vacuoles within the alveolar capillaries:Fat embolism typically occurs after long bone fractures and manifests with respiratory distress, petechial rash, and neurologic changes. This patient’s fracture was limited to the ankle, a smaller bone, and the rapid cardiovascular collapse suggests a massive occlusive event rather than fat embolism.
B. Thromboembolus occluding the branch of the left pulmonary artery to the left upper lobe:A segmental pulmonary embolus would cause localized hypoxemia and pleuritic pain but is unlikely to produce sudden unresponsiveness and pulseless electrical activity. The severity of this patient’s collapse suggests a more proximal obstruction.
C. Saddle pulmonary thromboembolus occluding the bifurcation of the pulmonary trunk:Massive pulmonary embolism, often termed a “saddle” embolus, can occlude the main pulmonary artery bifurcation, abruptly increasing pulmonary vascular resistance. This results in right ventricular failure, severe hypoxemia, pulseless electrical activity, and rapid death, consistent with this patient’s sudden deterioration four days post-surgery, with multiple risk factors including obesity and oral contraceptive use.
D. Acute myocardial infarct of the anterior wall of the left ventricle:Acute myocardial infarction can cause sudden death but typically presents with chest pain, ST-segment changes, or preceding ischemic symptoms. The immediate post-operative context and massive pulmonary compromise favor pulmonary embolism as the underlying cause.
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