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Trial of Labor in a Parturient with a History of Severe Asthma, A Multidisciplinary Team Approach
Abstract Number: T5C-2
Abstract Type: Case Report/Case Series
Asthma is one of the most common pre-existing conditions in pregnancy and multiple studies have found it to be associated with greater risk of several pregnancy complications: Gestational hypertension, preeclampsia, gestational diabetes, placental abruption, preterm delivery, postpartum hemorrhage, venous thromboembolism, caesarean section delivery, and maternal mortality. The mode and timing of delivery as well as anesthetic approach is complex and requires a multidisciplinary approach to planning the delivery, since maternal response to asthma treatment is unpredictable.
This is a case of a 31 year old woman G3P0020 with a working diagnosis of severe persistent asthma who presented to labor and delivery at 37 weeks gestational age for an induction of labor. She has a longstanding history of asthma diagnosed at age twelve with regular follow up with a pulmonologist and is managed with bronchodilators and frequent courses of systemic steroids for exacerbations. She has a history of multiple ICU admissions requiring intubation. There are several features of her underlying lung disease that are atypical for asthma including normal airway pressures immediately following intubation during prior exacerbations per discussion with her pulmonologist. During her exacerbations it was often noted that the patient had elevated lactate levels. Institution of mechanical ventilation usually corrected the metabolic disturbance, and the elevated lactates were attributed to increased work of breathing. The possibility of myopathy was considered. Muscle biopsy, EMG and neurology consult was completed with negative results as a clear delineation of her underlying disease remained elusive.
A multidisciplinary care plan was outlined for the patient with consultation from her pulmonologist. The obstetric plan was an elective induction of labor at 37 weeks with use of assisted delivery techniques to avoid fatigue and associated respiratory distress. The pulmonologist recommended continuation of her home regimen of budesonide BID and formoterol 15 mcg BID with the addition of albuterol/ipratropium every 4 hours and stress dose steroids with induction of labor. An arterial line was placed for blood gas monitoring. An early epidural was placed to avoid systemic opioids. The patient required vacuum assisted delivery and a healthy neonate was born with APGAR scores of eight and nine. Her delivery was complicated by retained placenta and associated postpartum hemorrhage of 1000mL.
This case challenged us to provide care for a parturient with severe asthma. There are many factors which need to be taken into consideration including limiting fatigue and stress with an early epidural, close monitoring of her respiratory status with clinical evaluation supplemented with blood gas analysis, coordination with the obstetrician for assisted delivery, and appropriate use of uterotonic agents.