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Management of Status Asthmaticus in a 24-Week Gestation Pregnancy: A Real Challenge FREE TO VIEW

Erwyn Ong*, MD; Amit Asija, MD; Aakanksha Asija, MD; Alberto Revelo, MD; Hossam Amin, MD; Nelky Ramirez, MD
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Metropolitan Hospital Center, New York, NY

Chest. 2012;142(4_MeetingAbstracts):347A. doi:10.1378/chest.1389758
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SESSION TYPE: Critical Care Student/Resident Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: The physiological changes of pregnancy can complicate the means of providing adequate ventilation and oxygenation to both the mother and the fetus (1). We present a case of status asthmaticus worsened during pegnancy and improved after fetal delivery

CASE PRESENTATION: A 18 year old female at 24 weeks of gestation with history of asthma was admitted to medical intensive care for asthma exacerbation. On examination, patient was in acute respiratory distress, tachypneic at rate of 30s, hypoxemic with oxygen saturation of 91% at room air, using accessory respiratory muscles, with tight wheezing despite intravenous steroids, frequent nebulizations, and antibiotic therapy for possible pneumonia. Patient was thus intubated and mechanically ventilated. Labs were significant for mild leukocytosis. Her systolic blood pressure was 180s and heart rate remained at 130s, not responding with antihypertensives, so cardizem drip was started. She was not adequately sedated with propofol, fentanyl and midazolam drips and was very uncomfortable with mechanical ventilation so she was paralyzed on Cisatracurium drip. Patient was maintained on high Peak pressure, Inspiration: Expiration ratio 1:5, high flow rate, low respiratory rate and low tidal volume. Her lung examination persistently showed wheezing without much improvement even after five days of aggressive asthma management. Her CXR worsened due to fluid overload. After a multidisciplinary meeting with family a decision was made to terminate the pregnancy via cesarean section. Two doses of Betamethasone were given for fetal lung maturation. After surgery, the patient improved significantly. Cisatracurium and Propofol drips were discontinued and patient was extubated two days postpartum. She was discharged on steroid taper and bronchodilators. Patient regained complete functional capacity and was blessed with a healthy baby boy.

DISCUSSION: Asthma is the most common chronic medical condition complicating pregnancy, with reported prevalence between 3-12%. Asthma exacerbations are more common during 2nd and 3rd trimester, and the course of the disease is unpredictable. Poor control of asthma is associated with adverse maternal and fetal outcomes: preeclampsia, uterine hemorrhage, preterm delivery, and low birth weight. In managing the pregnant patient with respiratory failure, intensivists and obstetricians confront the question especially when the patient is not in labor; if termination of pregnancy will improve the maternal condition. The benefit of delivery to improve respiratory failure in obstetric patient is not well established. The presented patient case above significantly improved clinically after fetal delivery.

CONCLUSIONS: Management of severe asthma exacerbation during pregnancy can become very challenging. Decision regarding early fetal delivery should be addressed.

1) Elsayegh, et al. Management of the Obstetric Patient with Status Asthmaticus. J Intensive Care Med 2008; 23: 396.

DISCLOSURE: The following authors have nothing to disclose: Erwyn Ong, Amit Asija, Aakanksha Asija, Alberto Revelo, Hossam Amin, Nelky Ramirez

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Metropolitan Hospital Center, New York, NY




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