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Double Trouble: A case of subglottic stenosis and thrombocytopenia in a parturient
Abstract Number: S-35
Abstract Type: Case Report/Case Series
A 39 y/o G2P1 at 30 wks EGA with h/o subglottic stenosis and immune thrombocytopenic purpura (ITP) presented for antepartum consultation. ENT examination revealed decreased vocal cord abduction, posterior glottic stenosis, and an anterior glottis web, all presumed secondary to prolonged neonatal intubation. During the visit, she was hoarse with dyspnea on exertion and had a Mallampati I with good mouth opening and jaw protrusion.
After multidisciplinary discussion, a scheduled cesarean delivery at 39 wks was planned with regional anesthetic if platelet levels were adequate and ENT on hand as airway backup. At presentation for delivery, patient’s platelets were 44k necessitating general anesthesia. She was adequately NPO with aspiration prophylaxis and received dexamethasone in anticipation of a difficult airway. A C-MAC provided a Grade I view, but a 5.0 MLT would not pass. ENT attempted passage of 4.5 ETT over flexible laryngoscope but could not maneuver the scope anteriorly through the cords. Ultimately, ENT performed direct laryngoscopy with a Miller, and successfully placed a 4.5 ETT with mild difficulty. Throughout, she was easy to mask with sats >85%. The case was uneventful and the patient was extubated.
Mild stridor and hoarse voice were noted POD #0, but the patient remained stable and was weaned to room air by discharge on POD #3. Approximately four months postpartum the patient was seen by ENT and determined stable to undergo a microdirect laryngoscopy with excision of the anterior glottis web.
Tracheal stenosis is rare during pregnancy, with fewer than 20 cases documented in literature. Patients can present with difficulty breathing or wheezing that is often misdiagnosed as asthma unresponsive to bronchodilators. Tracheal stenosis may be congenital or acquired. Acquired etiologies include trauma, prolonged intubation, GERD, and Wegener’s. Physiologic changes of pregnancy such as decreased FRC, increased oxygen consumption, airway mucosal swelling and weight gain can exacerbate tracheal stenosis symptoms.
There is no consensus on the optimal management of pregnant patients with tracheal stenosis. Some suggest that the safest method is insertion of tracheostomy tube under local anesthesia, while others describe successful bronchoscopic dilations during pregnancy.
On the other hand, thrombocytopenia is the second most common hematologic abnormality encountered during pregnancy after anemia. However, less than 1% of parturients present with platelets <100k. Minimum platelet count for neuraxial anesthesia depends on provider; however few are likely to place a neuraxial at <50K.
The combination of thrombocytopenia and tracheal stenosis during pregnancy is exceedingly rare, with no documented cases in the literature and such patients require intense multidisciplinary collaboration. Ultimately, we felt the safest plan was to avoid neuraxial anesthesia and proceed with general anesthesia with ENT on standby.