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Case Report: Post-partum Pre-eclampsia Complicated by ARDS and Cerebrovascular Accident in a Patient who is Status Post Cesarean Section for Uncontrolled Blood Pressure
Abstract Number: F5D-8
Abstract Type: Case Report/Case Series
Introduction: Acute respiratory distress syndrome (ARDS) and acute cerebrovascular accident (CVA) are complications that can occur during the peripartum period, and each disease process confers its own increase in morbidity and mortality for parturients1. Treatment plans for both ARDS and acute CVA are often similar to the non-pregnant population as data on each disease process during pregnancy is limited. We will discuss the post-operative management of a unique patient who suffered both from ARDS and acute CVA after the delivery of her first child.
Case report: A 35 year old G5P0 morbidly obese female (BMI of 49.5) with past medical history significant for poorly controlled type II diabetes mellitus and hypertension required cesarean section for elevated blood pressures (BP) at 37 weeks gestation. The primary mode of anesthesia was incremental dosing of a lumbar epidural catheter with 2% lidocaine, which facilitated a relatively uneventful surgery.
On post-operative day three, the patient experienced wheezing and progressive oxygen desaturation on supplemental oxygen. Additionally, at this time the patient had severe range blood pressures requiring IV antihypertensives. The patient ultimately required ICU admission for respiratory failure necessitating intubation and invasive BP monitoring. Chest x-ray was consistent with ARDS, and the patient was subsequently placed in the prone position and ventilation management followed the ARDSnet protocol2. The patient’s respiratory mechanics and parameters improved with proning and controlled lung-protective ventilation (facilitated by sedation and 48 hours of IV paralytics), but the patient ultimately failed extubation despite the aforementioned interventions. While attempting to wean the patient off the ventilator, the patient’s BP remained difficult to control, and the patient suffered from acute renal failure requiring CRRT. With improvement of the patient’s renal and pulmonary function, the patient demonstrated signs of altered mental status which prompted diagnostic imaging. Head CT was significant for an acute lacunar infarction. As the patient was outside the window for treatment with tissue plasminogen activator, management of the patient’s acute CVA was primarily achieved through strict BP control and secondary stroke prevention.
Discussion: Cases of post-partum pre-eclampsia complicated by both ARDS and acute CVA are extremely uncommon, and management requires prompt intervention and a multidisciplinary approach in order to minimize morbidity and mortality3. Our case highlights the importance and difficulties of BP and glucose control in the peripartum period.
1. Too, Wen, et al. 2018
2. Chiumello, Coppola, et al. 2018
3. Duarte. 2014