A Case Study of Preeclampsia and Pulmonary Edema: Why Can't We Get This Right?

Key Points

• Patient presented to OB triage at 36 weeks with shortness of breath, inability to lie flat, and cough, but initial assessment prioritized fetal monitoring over maternal vital signs.
• First documented blood pressure was severely elevated (202/122), with pulse oximetry at 91%, yet no respiratory rate was recorded for nearly 45 minutes.
• Physician ordered labetalol and albuterol from home without examining the patient, assuming new-onset asthma despite no history, and without developing a differential diagnosis.
• Treatment delays included no antihypertensive given for over 90 minutes, oxygen only started after calling respiratory therapy (hospital policy), and inadequate oxygen delivery (4-5 L face mask) for severe hypoxemia.
• Labs showed low albumin (2.6) and normal renal function, indicating preeclampsia with severe features and risk of pulmonary edema, but no urgent escalation or multidisciplinary response occurred.

Summary

This case highlights critical failures in the management of a 22-year-old primigravida at 36 weeks who presented to OB triage with shortness of breath, inability to lie flat, and cough. Despite being at a high-volume level III facility, her care was marked by delays, missed opportunities, and a lack of clinical urgency. Upon arrival, the triage nurse did not use an acuity tool, leading to a 20-minute wait before assessment. The initial vital signs revealed severe hypertension (202/122), tachycardia (114 bpm), and hypoxemia (pulse ox 91%), yet no respiratory rate was documented. The fetus was monitored first, reflecting a misprioritization of maternal versus fetal assessment. Repeat blood pressures confirmed severe range hypertension, but treatment was not initiated for over 90 minutes. The physician, called at home 45 minutes into the presentation, ordered labetalol and albuterol without evaluating the patient or considering a differential diagnosis. The albuterol order was based on an assumption of new-onset asthma, despite no history of pulmonary disease. This approach ignored the likely diagnosis of preeclampsia with severe features and pulmonary edema, given the patient’s low albumin (2.6), normal renal function, and progressive hypoxemia. The nurse did not activate the hospital’s rapid response team (RRT), even though the vital signs met criteria, and oxygen was delayed because hospital policy required a physician order or respiratory therapist to initiate it. When oxygen was finally started, it was at 4-5 L via face mask, which is inadequate for a patient with a pulse ox of 87% on room air. Continuous pulse oximetry was not documented, and no respiratory rate was recorded until 33 breaths per minute nearly an hour into the encounter. Antihypertensive therapy with labetalol 20 mg IV was given after 90 minutes, but it was ineffective, and a second dose of 40 mg was given 30 minutes later. Throughout this period, there was no escalation of care, no bedside physician evaluation, and no anticipation of the need for positive pressure ventilation or ICU transfer. The case underscores the importance of timely maternal assessment, use of triage acuity tools, activation of RRT for severe hypertension and hypoxemia, and the need for a thorough differential diagnosis in pregnant patients with respiratory symptoms. It also highlights system issues such as restrictive oxygen policies and the lack of continuous maternal monitoring, which can delay life-saving interventions.