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A CASE OF A BRONCHIAL ARTERIOVENOUS MALFORMATION PRESENTING AS HEMOPTYSIS DURING PREGNANCY
Abstract Number: RF4BD-355
Abstract Type: Case Report Case Series
INTRODUCTION: Airway management in the pregnant patient poses a challenge for the anesthesiologist as well as a significant risk for both the parturient and the baby . This risk is exaggerated in patients with pathological variations in airway anatomy such as arteriovenous malformations due to a combination of anatomical airway changes including engorgement of mucosal capillaries and edema from fluid retention .
CASE: Our patient is a 44 year-old G5P4A0 female who presented at 29 weeks gestation with sudden onset hemoptysis after returning from Congo. She had no medical history and an uncomplicated pregnancy. She was tachycardic but otherwise stable. Initial labs showed anemia but diagnostic tests did not point to a clear diagnosis. Chest x-ray was unremarkable and a CT scan for pulmonary embolism was inconclusive due to an inadequate contrast load.
She was initially started on a heparin infusion which was later stopped after worsening hemoptysis and closer review of her imaging with the radiologists. She was intubated and underwent bronchoscopy with the interventional pulmonology (IP) team which revealed a large clot occluding the proximal right main stem but no obvious source of active bleeding. Pulmonary angiography demonstrated a hypertrophied right bronchial artery with 2 large branches supplying an abnormal region of hypervascularity in the right lower and middle lobes which were embolized. Repeat bronchoscopy demonstrated an old clot at the same location, therefore, after discussion with the IP, intensive care and anesthesia teams, the decision was made to keep the patient intubated due to concern for re-bleeding.
On hospital day 7, a non-reassuring fetal heart rate pattern was observed and the patient was taken for an emergency cesarean section under general anesthesia given she was already intubated. A fiberoptic scope, double-lumen endotracheal tube and bronchial blocker were kept available in case of rebleeding. Careful attention was paid to maintain airway pressures between 17–20 cmH2O. Delivery was successful and the patient was extubated 5 days later with no recurrence of hemoptysis.
DISCUSSION: Early involvement of a multidisciplinary team is critical in the timely diagnosis and management of rare pulmonary pathology. In our pregnant patient particularly, this was exemplified in the efforts of the radiology, interventional pulmonology, anesthesia, obstetrics and critical care team which led to a safe delivery despite a complex presentation .
1. Pouwels, H. M., et al. (1992), Systemic to pulmonary vascular malformation, Eur Respir J 5(10): 1288-1291
2. Bhavani-Shankar K, et al, Airway Changes during Labor and Delivery. Anesthesiology 2008;108(3):357-362
3. Lee, JK, et al, Embolization of multiple systemic artery to pulmonary artery fistula with recurrent hemoptysis. Tuberc Respir Dis (Seoul) 75(3): 120-124