Young woman with recurrent pregnancy loss.

A woman in her 30s was referred to our clinic as a part of the workup for recurrent pregnancy loss. She had not been evaluated for any cardiovascular illness previously. The patient had easy fatigability with a functional status of New York Heart Association class II. Cardiovascular examination revealed a parasternal heave, narrow splitting of the second heart sound with a loud pulmonary component and an early diastolic murmur of pulmonary regurgitation. An important clinical sign is shown in figure 1. Figure 1 A clinical sign in pulmonary hypertension. What is the diagnosis? 1. Idiopathic pulmonary artery hypertension 2. Patent ductus arteriosus with Eisenmenger syndrome 3. Ventricular septal defect with Eisenmenger syndrome 4. Atrial septal defect with severe pulmonary hypertension The image shows differential cyanosis …