Refractory Hypoxemia Leading to Cardiopulmonary Arrest in a Parturient with Acute Pulmonary Edema
Abstract Number: F-27
Abstract Type: Case Report/Case Series
Introduction: Pulmonary edema is associated with preeclampsia in 3% of cases (1,2) and acute hypoxemic respiratory failure in the parturient is even more rare. This case discusses the management of a parturient at 31 weeks gestation with severe preeclampsia complicated by pulmonary edema, severe maternal hypoxemia, and respiratory failure.
Case: This case report describes a 35 year old African-American female, G6P1041, with history of glucose-6-phosphate dehydrogenase deficiency, systemic lupus erythematosus (SLE), antiphospholipid syndrome, two pulmonary embolisms on fondaparinux and polycystic kidney disease with nephrotic range proteinuria who was admitted at 28 weeks gestation for vaginal bleeding. Her admission was complicated by proteinuria due to a combination of SLE exacerbation, severe preeclampsia and acute renal failure. She was also on therapeutic heparin given her hypercoagulable state. She was taken to operating room emergently for a stat C-section due to respiratory failure and severe hypoxia with an initial arterial blood gas value of 7.36/33/34/18/-6 on room air. Maximum saturation before induction was only 86%. After induction, the patient was noted to expel frothy secretions, which continued to after placement of endotracheal tube. She was refractory to conventional treatment of her pulmonary edema induced hypoxia, which included furosemide, suctioning, hand-ventilation, PEEP 20 mmHg. The patient underwent hypoxic arrest and subsequent code level medication enabled return of sinus rhythm. After assistance from cardiac anesthesiology, a TEE displayed only severe mitral regurgitation and left ventricular hypertrophy with no indication of myocardial infarction or volume depletion. The patient was given vasoactive substances, put onto an APRV ventilator mode and given nitric oxide with improving result. The patient underwent caesarian delivery and was stable enough to transfer to MICU, where on POD#4 was extubated with minimal complication after being treated for acute respiratory distress syndrome, acute renal failure and lupus exacerbation.
Discussion: Acute pulmonary edema is a serious complication in the setting of severe preeclampsia, acute SLE exacerbation and renal failure. Underlying cardiac pathology such as subendocardial ischemia in setting of severe left ventricular hypertrophy lead to mitral regurgitation and finally producing fulminant pulmonary edema.