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To Deliver or Not To Deliver?- A Unique Case of a Critically Ill Pregnant Woman
Abstract Number: F4C-4
Abstract Type: Case Report/Case Series
Preterm delivery is a primary cause of neonatal death. Babies born younger than 28 weeks, about half can suffer from respiratory distress syndrome and many have neurological disability. Although the avoidance of preterm delivery is a goal, this may not always be possible in critically ill patients. When parturients have life-threatening illness, management for delivery should involve multiple sub-specialties with close communication regarding triggers for delivery.
A 35 yo G7P6 female at ~26w+3 with PMH of traumatic brain injury, developmental delay, hypothyroidism, and asthma presented to the ED due to difficulty in breathing. In the next 24 hrs, her respiratory status worsened and required 5L nasal cannula to maintain saturation > 95%. Antibiotics were initiated and pulmonary embolism was ruled out by CTPE protocol. Increasing oxygen requirement and hypoxia (O2 sat 80s) necessitated transfer to ICU and intubation by anesthesiology with OB service at bedside. Despite worsening respiratory status, delivery would only be performed for maternal cardiac arrest. Airway management was complicated due to acute desaturation after induction and aspiration during intubation. Fetal deceleration and prolonged fetal bradycardia occurred, but the anesthesiology team alerted OB team to delay delivery and allow for stabilization once ETT confirmed. FHT normalized and a post-intubation bronchoscopy performed. The hospital course was complicated with ARDS, diffuse alveolar hemorrhage and sepsis. Daily assessments by OB and anesthesiology teams continued to recommend delay in delivery. She was extubated two days later, but then required a second intubation the following day. After 10 days of mechanical ventilation, aggressive antibiotic treatment, and steroid treatment for DAH she was discharged from the ICU with a viable fetus.
Discussion: In the setting of her acute respiratory distress, a multidisciplinary approach involving the ICU team, high risk OB team, neonatal ICU team, and anesthesia was implemented quickly with efficient and critical communication. At the time of intubation, high risk OB and neonatal ICU team were at bedside in the medicine ICU if emergent delivery of the baby became necessary. Fetal heart tones were appropriately monitored during intubation but communication facilitated the delay of delivery and stabilization of the patient. The patient had respiratory failure, which may be improved with delivery of the fetus, but all teams agreed to delay delivery prior to proceeding with emergency intubation. Good communication and trust avoided an emergency delivery in the ICU that may have put the mother at risk for acute blood loss, further infection and injury to internal organs and resulted in extreme preterm delivery. Recognition of the potential outcome of pregnant patient in such high risk and high acuity scenarios is crucial for the anesthesiologist in helping to direct care.