Fatal Cardiopulmonary Collapse, Bilateral Pleural Effusion, and Hypoxic En-cephalopathy in Neglected Severe Preeclampsia: A Case Report on Antenatal Surveillance and Access Gaps

Abstract

Background: Preeclampsia is a leading cause of maternal death worldwide. Where antenatal care (ANC) is absent and women lack health insurance, a hypertensive crisis can progress quickly to fatal multi-organ failure.

Objective: To describe the clinical, hemodynamic, and laboratory course of fatal postpartum cardiopulmonary collapse after unmonitored severe preeclampsia.

Methods: Single-patient case report (CARE guideline) at Dr. Saiful Anwar General Hospital, Malang, Indonesia. Clinical findings, serial laboratory values, arterial blood gases, echocardiography, ultrasonography, and chest radiography were recorded over nine days of intensive care and presented chronologically, with a descriptive comparison with the literature.

Results: A 44-year-old uninsured primiparous woman with no ANC contacts had an emergency cesarean delivery for severe preeclampsia and left a secondary hospital against medical advice on postoperative day 2 because of financial hardship. At tertiary admission she was obtunded (Glasgow Coma Scale 13), with blood pressure 166/94 mmHg, hemoglobin 5.5 g/dL, and oliguria. Radiography showed large asymmetric bilateral pleural effusions (left ~1,250 mL) with compressive atelectasis; PaO₂/FiO₂ was 142.1 mmHg. Echocardiography showed concentric left ventricular hypertrophy, systemic vascular resistance 2,140 dyn·s/cm⁵, and E/e' 17.8 (PCWP ~24 mmHg). Despite mechanical ventilation, nicardipine, transfusions, and albumin, anuric renal failure (creatinine 5.20 mg/dL) and severe acidosis (pH 7.08, lactate 11.4 mmol/L) progressed, and cardiopulmonary arrest occurred on day 9.

Conclusion: In this patient, unmonitored severe preeclampsia was followed by fatal cardiopulmonary collapse; hydrostatic overload and endothelial hyperpermeability are proposed mechanisms that were not directly measured. Emergency coverage at private obstetric facilities may help prevent premature discharge.