Case Conference: Respiratory Failure in Term Pregnancy

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Case ConferenceRespiratory Failure inTerm
Pregnancy

• James Pointer, MD, FACEP
• Medical Director
• Alameda County EMS

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The Call

• 2/16/01 0232 CC SOB
• Pt. was Cambodian-speaking only, 42y/o woman
  c/o SOB since yesterday, worsening tonight.
• Thru a translator described chest tightness,
  pain coming from abdomen (pt. 9 mos. pregnant)
  and
• cough (unproductive).
• Pt. progressively and noticeably
• worsened en route.

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0313 Room 21

• CC SOB
• HPI
• 42yo woman - G6P6 (with twins this pregnancy)
  with hx HTN DM presents with acute SOB tonight.
  
• 9 mos. preg. -- EDD 2/22. Saw Ob yesterday, EDD
  moved to March. Ø SZ.
• PMH GDM, PIH, amniocentesis x 2 normal
• Meds Insulin, PNVs, Robitussin
• NKDA

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History (cont.)

• Social history
• Married, six children ages 14 and up.
• Unplanned pregnancy, husband wanted to keep, pt.
  did not.
• Hx domestic violence, resolved.
• Review of systems
• Nonproductive cough since 30wk EGA
• chest tightness
• abdominal pain

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Physical exam

• Vital signs
• T 99.4 pr, BP 230/130, HR 130s, RR 30s SpO2 92
  on 10L by FM
• General
• Very distressed, grasping companions, asking for
  help, breathing as if drowning
• Resp
• Sitting straight up, rales 1/2way up bilaterally
• CVS
• tachy, reg, 2 pitting edema bilaterally, ø
  JVD

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Physical exam (cont.)

• GI
• distended, full belly
• GU
• ø crowning
• Skin
• cool, wet skin (diaphoretic)
• Neuro
• moving all 4s, very distressed

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Labs Studies
ALT 27 AST 35 Alk ø 187 Ca 8.0 Tbili
0.8 Alb 3.2 Tprot 6.9
PT 9.3 INR 0.79 aPTT 25.5 Fibrinogen
601 D-dimer 12 ßhCG 18,600
CXR small lung fields, pulm edema
UA 1.010/6.0/100 protein/sm blood
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ED Course

• 0315
• Vital signs B/P-210/130, P-155, RR- 36
  Pulse Ox-88 with 100 mask
• 0318
• pCXR
• 0320
• IV pulled out
• 0321
• NTG 1 tab SL, 18ga. IV placed
• 0327
• MSO4 4mg

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ED Course (cont.)

• 0322
• Alb/Atro via HHN
• 0323
• 220/138, 160
• Ultrasound in progress
• 0325
• Lasix 40mg, second IV placed
• 0330
• 130/90 82, labs drawn sent,
• Etomidate 10mg, succinylcholine 120mg

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ED Course (cont.)

• 0332
• Intubated with 7.5 ETT.
• 161/98 150 100
• 0336
• Dr. Neblett, Ob, arrives. FHR 74.
• 172/120 133 99.4 AC 15/450/100
• Packaging pt. to OR, Foley placed.
• 0345
• Mg 4g IVP over 15min.
• 0347
• Pt. to OR on monitor.

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OR Course

• 0350
• Pt. in room, shaking head, rocuronium 30mg IV.
  Monitor applied.
• HR 20s, SpO2 10.
• Idioventricular rhythm, no pulse,
• CPR with chest comp started.
• Defib 250J, epi 1.0 mg.
• 0359
• I.V. rhythm. Midline abd incision.
• Defib 300J, epi 1.0mg, NaHCO3 1 amp.

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OR Course (cont.)

• 0403
• Baby boy A Apgars 2/5/8. Pt. defib 350J, epi
  1.0mg. Asystole.
• 0404
• Baby boy B Apgars 1/3/5.
• 0410 Pt. pronounced dead.

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Pulmonary Edema in Term Pregnancy Differential
Diagnosis

• Severe preeclampsia
• Amniotic fluid embolism
• Peripartum cardiomyopathy
• Pulmonary embolism
• CHF -- other etiology

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Preeclampsia

• Common complication of term pregnancy
• Pathophysiology poorly understood
• Criteria
• hypertension
• proteinuria
• edema
• Eclampsia seizures
• More common at extremes of age/parity

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Pulmonary Edema in Preeclampsia

• 2.9 of severe preeclamptics
• Not an isolated complication
• Age, parity increase risk
• Associated with fluid administration
• High maternal/perinatal MM

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Preeclampsia Treatment

• Magnesium sulfate IV
• 4-6g IVP, then drip
• Blood pressure management
• Prompt delivery of the baby

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Amniotic Fluid Embolism (AFE)

• Rare 1/8000 - 1/80,000 deliveries
• 10-15 of 1st world perinatal mortality
• Usually during labor
• Abruption, membrane rupture predispose
• Maternal mortality 60-80

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AFE Presentation

• Hypoxia
• Hypotension
• Fetal bradycardia
• Seizure (50)
• DIC (later)

Rapid onset 50 dead in 1hour
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AFE Pathogenesis

• Anaphylactoid syndrome of pregnancy
• Pulmonary vasospasm?
• Myocardial depression
• Procoagulant effects of fetal antigens
• Evil humors
• endothelin, ?PGF2,
• histamine, ? bradykinins,
• leukotrienes, ? thromboxane

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AFE Diagnosis

• Microscopic slides neither specific/sensitive
• Clinical (4/5)
• Hypotension or cardiac arrest
• Hypoxia
• Coagulopathy
• Absence of other explanation
• Peripartum onset

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AFE Management

• Supportive only
• Maintain SpO2 and BP
• Correct DIC
• Treat uterine atony
• Fetal monitoring/delivery

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AFE Prognosis

• Maternal survival 20-40
• 15 survived neurologically intact
• Maternal cardiac arrest
• 68 babies survive
• 50 of these neurologically normal

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PeripartumCardiomyopathy

• Dilated cardiomyopathy ? CHF
• Onset last trimester - 6 mo. postpartum
• Cause unknown
• High risk patients
• African-American
• Multiparous
• Age gt30

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PeripartumCardiomyopathy (cont.)

• Treat like regular CHF
• Mortality 25-50
• May recover completely
• Avoid future pregnancies

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PerimortemCesarean Section

• 52 fetal survival (case series of 72)
• 15 discharged home
• Survival decreases with longer delivery time
• Fetal survival gt25 min. after moms death?
• Indicated when uterus above umbilicus

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Perimortem Cesarean

• Midline, xyphoid to pubis, incision
• Vertical uterine incision (avoid bladder)
• Cut through placenta if necessary
• Deliver baby(ies) and placenta
• Clamp cord ASAP

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Take-home Points

• ABCs always useful
• Always think of magnesium
• Mom comes first
• Perimortem C-section is an option
• Rapid transport

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