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A 35-year-old woman, who is 39 weeks' pregnant, is evaluated in the office because of progressive dyspnea of 13 days' duration. She was previously asymptomatic and has no history of cardiovascular disease. This pregnancy is her first. Physical examination shows a jugular venous pressure of 13 cm H2O, a diffuse apical impulse, an apical holosystolic murmur, and a third heart sound. Crackles are noted in both lungs. An electrocardiogram shows sinus tachycardia, but is otherwise normal.

Which of the following is the most likely diagnosis?

( A ) Aortic valve stenosis
( B ) Atrial septal defect
( C ) Mitral stenosis
( D ) Peripartum cardiomyopathy
( E ) Tricuspid valve regurgitation


There are many questions related to medicine in OB, this is one


Holosystolic murmur... out the answers...TR is the likely cause.




I would say D as well. TR would not give crackles in lungs.




Guys, you are right - it is TR but is BECAUSE OF cardiomyopathy!
Sign of cardiomyopathy:
-elevated jugular venous pressure
- cardiomegaly
- third heart sound
- loud pulmonic component of the second heart sound
- mitral and/or tricuspid regurgitation
- pulmonary rales
- peripheral edema
- ascites
- arrhythmias
- embolic phenomenon
- hepatomegaly
ECG- normal/sinus tachycardia/atrial fibrillation.


So...wat is the final answer?


TR as a cause of wonder how often it causes it... It will however elevate CV. The ECG will show signs of CM.. voltage, Axis shift etc. S3 is the sign of the ventricular overload...for any reason...including volume expansion as in pregnancy..


I think the most accurate answer is PERIPARTUM CARDIOMYOPATHY ...

No need to confuse with TR since the holosystolic murmur is APICAL...nod


Ill pick D as best answer .. TR will not be apical ..


TR IS in fact apical.


sorry...continuation, when there is RV dilation, which in this case may be present, due to other findings that are described. I agree, that CM can certainly be present with such descrption, but the murmur does not fit.


So is D or E?
I go with TR



TR leads to right axis shift in ECG, cardiomyopathy leads to signs of hypertrophy in ECG, as well as repolarisation disturbances. Crackles heard over the lungs and the elevated JVP result from pulmonary congestion, 2nd to MS.
BTW: it is not that uncommon for MS to demask during pregnancy (high cardiac output!)


Mitral Stenosis does not give you apical holosystolic murmur.
You are correct about the other things


mitral stenosis does give an apical holodiastolic murmur, right!
but you actually should not make the diagnosis on the basis of auscultation:
- interindividual differences in hearing capabilities and interpretation
- the volume of what you hear does not necessarily reflect the severity of the underlying pathology

If you hear a murmur with clinical relevance (this is actually one), do additional testing (TTE, TEE).

Edited by farnsworth on Apr 15, 2008 - 6:53 AM




bump is there any answer to this question i go with cardiomyopathy


thnx 4 the bump.. ya... i agree with D) cardiomyopathy. Well-rounded dx instead of only a part of it.

TR (only a piece of the puzzle) can get worse to heart failure.. hence causing the crackles in lung, dyspnea. Heart failure can result in TR.

age and pregnancy helps towards development of the disease who has been asx before.

note: holosystolic murmurs --> T.regurg. M. Regurg. (also VSD)

next step in management: Echocardiogram!

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