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An unusual case of restrictive lung disease in the parturient: aggressive tubercular disease
Abstract Number: S-70
Abstract Type: Case Report/Case Series
Introduction: Restrictive lung disease in the parturient is rare.(1) Restrictive lung disease may be due to musculoskeletal abnormalities, interstitial lung diseases, or post-infectious complications from tuberculosis. In developed nations, many post-infectious respiratory sequelae are rarely encountered due to aggressive public health efforts that have reduced primary infection of tuberculosis. We present the management of a cesarean delivery in a woman with advanced tuberculosis destruction of her lungs causing clinically significant respiratory distress.
Case: Our patient is a 33 year old G2P1 at 34 5/7 weeks gestation presented to our institution with progressive dyspnea at rest and orthopnea. Medical history included asthma and remote TB infection with multidrug treatment. Pulmonary function test revealed severe restrictive lung disease with an FVC of 1L (5% predicted) and FEV1 of 0.75L (4% predicted). ABG demonstrated hypercarbia, hypoxemia, and anemia. Chest x-Ray (Figure 1) showed bilateral apical scaring, bronchiectasis, and right upper lobe cystic mass. TTE demonstrated normal cardiac function with possible pulmonary hypertension. MFM, anesthesiology, neonatology, cardiology and ICU services met for multidisciplinary planning. Due to deterioration of pulmonary status, the decision was made to proceed with primary cesarean delivery under general anesthesia. The patient demonstrated significant intraoperative hemodynamic instability requiring aggressive management including transfusion and pressors. Cardiac assessment via TEE guided medication administration and transfusion therapy. Both mother and baby required admission to the intensive care unit for ventilator weaning and were discharged home on postoperative day #6.
Discussion: Severe restrictive lung disease with pulmonary hypertension is a relative contraindication to pregnancy. (2) Fortunately, many of the causes of restrictive lung disease do not typically affect patients of childbearing age. Post-infectious sequelae from tuberculosis are rarely seen in industrialized countries, especially in immunocompetent patients. This case demonstrates the necessity of multidisciplinary management of rare disease states to maximize perioperative safety and to ensure good outcomes for both mother and baby.
1) Lapinsky SE et al. Chest. 2014;145(2):394-398.
2) Van de Velde M, et al. Maternal Critical Care: A Multidisciplinary Approach. Cambridge UP, 2013.