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Management of Symptomatic Subglottic Stenosis and Tracheal Dilatation Procedure in Pregnancy
Abstract Number: T-38
Abstract Type: Case Report/Case Series
Symptomatic subglottic stenosis (SGS) is very rare in the child-bearing women. Few case reports exist in the literature.(1) This disorder presents dilemmas in obstetrical, surgical and anesthetic management of the pregnancy. Antepartum recognition of SGS is imperative, as management of unrecognized SGS can be life threatening for the mother and neonate during delivery.(2)
Our patient was a 33 year old G3P2 female with 60% SGS originally discovered before this pregnancy because of cough, wheezing, shortness of breath and stridor on exertion. The symptoms worsened with pregnancy, as had the stenosis. A prior URI had markedly increased symptoms which decreased with a methylprednisolone taper. She had a history of reflux disease (treated with omeprazole), but otherwise was healthy. The cause of the stenosis was judged idiopathic. She had 2 prior cesarean sections (one emergent). Otolaryngology management included one prior tracheal balloon dilatation under general anesthesia with a normal laryngoscope view, but intubation with a 5.0 endotracheal tube. After multidisciplinary consultation, we met her at 37 weeks for an elective low transverse cesarean section and tubal ligation, to be followed by tracheal dilation under general anesthesia. Patient exam revealed a BMI of 38, distant basilar breath sounds, mild stridor and scattered wheezes on deep breathing. She had a MP class 2 airway score. RR 20 (unlabored at rest) with other vitals normal, and the ability to lie partially reclined. She was NPO and consented for a combined spinal epidural anesthetic for delivery, followed by general anesthesia for the dilatation. Consent was also obtained for tracheostomy if intubation was not possible. The ENT surgeon was present throughout the surgeries, and had reviewed the patient CT scan with the anesthesiologist which showed stenosis below the cricoid ring to the 2nd tracheal ring. Anesthesia and surgery for delivery were uneventful, with a healthy female delivered. After uterine repair and closure, the patient underwent induction of general anesthesia, with a modified rapid sequence induction ensuring adequate face mask ventilation, then an uncomplicated intubation, again with a 5.0 endotracheal tube. Tracheal balloon dilatation and emergence from general anesthesia were also uneventful, as was postoperative course.
Various conditions can cause SGS including trauma, GERD, Wegener’s granulomatosis, autoimmune diseases, papillomatosis,TB,anatomical deformities, or neoplasm.(3) Idiopathic SGS occurs more often in women and can be exacerbated by hormonal and physiologic changes of pregnancy. Unrecognized SGS can lead to disasters in airway management, especially with repeated intubation attempts. The intrapartum management of SGS requires good multidisciplinary communication, consultation,and logistical coordinaton of patient care.
1. Anesthesia Intensive Care 2003;31:576-7
2. Indian J Anaesth 2011 55(5):521-23
3. Radiol Med 2007; 112:1132-4