Answer to the last #DiagnosticDilemma
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The answer to the last Diagnostic Dilemma (A 24-week pregnant 18-year-old presented with acute respiratory distress and collapse. Her blood pressure was 222/78 mm Hg, pulse was 39 beats per minute, and she had weak radial pulses and absent pulses in her lower limbs) is D. All the above

She had been found to have hypertension at the age of 15 years but was not on any medication. At her first antenatal visit, 17 weeks into the pregnancy, her blood pressure was 150/95 mm Hg. At 20 weeks, it remained high at 170/85 mm Hg. She had prominent neck pulsations with a thrill audible over the carotid arteries. She had normal radial artery pulses in both arms, no pedal or popliteal pulses, and weak, regular femoral pulses that varied in intensity, with radiofemoral delay. Her apex beat was displaced to the sixth intercostal space lateral to the midclavicular line and was pressure loaded. Urine dipstick analysis showed 1+ proteinuria and 4+ blood. She was anaemic with a haemoglobin concentration of 8·6 g/dL. The C-reactive protein concentration was 40 mg/L, and her erythrocyte sedimentation rate was 108 mm/h. A chest x-ray showed an enlarged heart and early rib notching. An electrocardiogram showed Mobitz type II heart block. She required transvenous pacing after which she was extubated. Echocardiography showed a non-dilated, moderately hypertrophied left ventricle with good systolic function, a trileaflet aortic valve—with no root aneurysm— and a small restrictive ventricular septal defect.

A tapering aortic arch was noted with no diastolic flow in the descending aorta and a diastolic tail in the abdominal aorta. A CT angiogram showed severe aortic coarctation 2 cm distal to the left subclavian artery with functional aortic interruption, and an aortic isthmus of 2 mm with collateral circulation. The patient’s blood pressure remained uncontrolled for over 48 h—despite infusions of labetalol and nitrate. Doctors decided to dilate and stent the occlusion: the coarctation was crossed—with a degree of difficulty—via access from the left radial and right femoral arteries. Sequential balloon dilation was done, and a stent inserted. The patient’s blood pressure decreased postoperatively, and a permanent pacemaker was inserted a few days later. She was discharged on methyldopa, which was stopped 4 weeks later. At 36 weeks of gestation, the woman developed preeclampsia: labour was induced, and she delivered a healthy baby girl weighing 2 kg with a 5-min Apgar score of 10. Coarctation of the aorta is an important cause of secondary hypertension usually presenting in early childhood; treatment—as this patient illustrates—can be particularly challenging in cases found for the first time in pregnancy.

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Source: The Lancet
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