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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 112-114

Management of kyphoscoliotic pregnant patient presenting with impending respiratory failure – A case report


Department of Anaesthesiology and Critical Care, Pt BD Sharma, PGIMS, Rohtak, Haryana, India

Date of Submission23-Aug-2021
Date of Acceptance21-May-2021
Date of Web Publication01-Oct-2021

Correspondence Address:
Dr. Renu Bala
Department of Anaesthesiology and Critical Care, Pt BD Sharma, PGIMS, Rohtak, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacc.JOACC_92_20

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  Abstract 


Pregnancy with kyphoscoliosis is relatively a rare condition. Cardiopulmonary compromise due to mechanical restriction associated with spine deformity is exacerbated by pregnancy-related respiratory changes. We successfully managed a pregnant patient with kyphoscoliosis who reported to us in her third trimester with impending respiratory failure.

Keywords: Critical care, kyphoscoliosis, pregnancy, respiratory failure


How to cite this article:
Shashikiran, Bala R. Management of kyphoscoliotic pregnant patient presenting with impending respiratory failure – A case report. J Obstet Anaesth Crit Care 2021;11:112-4

How to cite this URL:
Shashikiran, Bala R. Management of kyphoscoliotic pregnant patient presenting with impending respiratory failure – A case report. J Obstet Anaesth Crit Care [serial online] 2021 [cited 2021 Dec 9];11:112-4. Available from: https://www.joacc.com/text.asp?2021/11/2/112/327417




  Introduction Top


Kyphoscoliosis is defined as an abnormal curvature of the spine in both the coronal and sagittal planes. The prevalence in the general population varies significantly from 0.3% to 15.3%. Such patients have impairment of pulmonary functions secondary to restrictive pulmonary dysfunction.[1],[2] Women with extremely severe spinal deformities are commonly considered to have high-risk pregnancies. Furthermore, parturients with severe kyphoscoliosis may present with an acute respiratory failure precipitated by acute pulmonary edema or pulmonary hypertension, requiring mechanical ventilation.[3],[4] We describe management of a pregnant female having severe kyphoscoliosis who presented in the Intensive Care Unit (ICU) with acute respiratory failure.


  Case – Report Top


A 23-year-old primigravida at 36 weeks of pregnancy presented with a history of dyspnea, cough, and fever of 1 week duration. The patient was drowsy but conscious and oriented, having tachycardia (pulse = 110/min), tachypnoea (respiratory rate = 50/min), blood pressure of 150/90 mmHg, and oxygen saturation of 86% on oxygen at the flow rate of 15 L/min by venturi mask (60%). General physical examination revealed that she was short-statured (height = 120 cm) weighing34 kg with severe dorsal kyphoscoliosis. On auscultation, bilateral inspiratory crackles were heard all over the chest, her heart sounds were normal. Chest X-ray (already done before admission –[Figure 1].) showed severe chest deformity and bilateral infiltrates. Obstetric examination showed normal fetal heart rate (120/min, regular). The cobb's angle measured was 105 degrees. Arterial blood gas (ABG) analysis showed respiratory acidosis and hypoxia. Other investigations such as complete blood counts, renal functions, and liver functions were within normal limits. The diagnosis of pregnancy with impending respiratory failure due to restrictive lung disease was made.
Figure 1: X ray of spine showing deformity

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Initially, noninvasive ventilation was commenced, but she continued to deteriorate. Eventually, her trachea was intubated, and mechanical ventilation was done (mode- pressure control, pressure limit-30 cm H2O, peak end-expiratory pressure (PEEP)-10 cm H2O, FiO2-1.0 delivering a tidal volume of 210–230 mL). The treatment comprised antibiotics, furosemide, dexamethasone, morphine, and midazolam and vecuronium infusion. Fetal ultrasonography revealed live fetus with normal lung maturity and development. Echocardiography showed pulmonary hypertension; sildenephil (20 mg) 8 hourly was commenced through a nasogastric tube.

On the second day, vecuronium was stopped, and the ventilator mode was changed to synchronized intermittent mandatory ventilation with a tidal volume of 340 mL, pressure support of 30 cm H2O, positive end-expiratory pressures (PEEP) of 10 cm H2O, and FiO2 of 0.6. All the investigations such as complete hemogram, liver function tests, and renal functions were normal, and vitals (heart rate, blood pressure) were maintained, though on auscultation of the chest, bilateral crackles were still present. The patient was showing gradual improvement in terms of blood gases, and fetal well-being was assessed daily. Obstetricians planned for elective cesarean in view of cephalopelvic disproportion on completion of 37 weeks, and morphine was planned to be stopped 72 h before surgery. Daily, the patient was assessed for extubation after switching off sedatives, but the extubation trial remained unsuccessful. She was maintaining saturation on pressure support of 12 cmH2O.

But on the 5th day of admission to the ICU, the patient went into labor, and an emergency cesarean section was done. The standard protocol of thiopentone, fentanyl, and atracurium was followed. The intraoperative course was uneventful. A 2.5 kg healthy baby with an Apgar score of 8 was delivered, and the patient was shifted back to the ICU. Elective ventilation was done for a day followed by weaning with pressure support ventilation on the second postoperative day. On the 8th day, she was extubated and kept on noninvasive ventilation. On succeeding days, chest physiotherapy was done, and she was able to maintain oxygen saturation on the venti-mask with minimal oxygen flow. Finally, she was shifted to the ward on the 12th day.




  Discussion Top


Management of pregnant patients with severe kyphoscoliosis is very challenging. There are few reports in the literature, which describe anesthetic management of these patients undergoing cesarean section, but the critical care of these patients during pregnancy is not much talked about.[5],[6]

The severity of kyphoscoliosis is determined by cobb's angle. If it is above 60 degrees, there is a progressive pulmonary and cardiac failure. However, the progression of the disease is reduced when the angle is more than 80 degrees due to rigidity caused by osteoarthrosis or fusion of some segments.[7]

During pregnancy, the thoracic cage normally expands in anteroposterior and transverse diameters with a reduction in airway resistance due to increased blood levels of progesterone. Inspired volume in pregnant women largely depends upon diaphragmatic excursion. In kyphoscoliotic (KS) patients, the diaphragm is entirely responsible for all increments in minute ventilation. Diaphragmatic activity is constrained as the enlarging uterus enters the abdominal cavity in midgestation, thus, decreasing functional residual capacity (FRC) and closing capacity (CC). A decrease in FRC and CC more than the anticipated values results in ventilation-perfusion mismatch and reduced arterial oxygen content.[5],[7]

In patients with KS, due to restrictive lung disease, the rise in tidal volume is not possible, and the increased minute ventilation is achieved via increased respiratory rate, thus, elevating work of breathing. KS patients with already increased peripheral vascular resistance may not be able to achieve increased cardiac output (which occurs in normal pregnancy) without further increments in vascular pressure placing an intolerable load on the right ventricles precipitating right heart failure. Fixed pulmonary hypertension unresponsive to supplemental oxygen therapy carries a grave prognosis.[7]

Our patient came in the third trimester with severe cardiorespiratory distress. We tried to manage the patient with NIV, but it failed; thus, elective ventilation was done. She also had pulmonary edema for which we preferred pressure control ventilation with high PEEP. After extubation, NIV was well tolerated, and chest physiotherapy helped in improving lung functions. Earlier, Kahler et al.[4] managed a pregnant kyphoscoliotic patient who reported in the second trimester. Noninvasive positive pressure ventilation and bilevel positive airway pressure (BIPAP) were able to alleviate respiratory distress. Following cesarean section, home nocturnal ventilator support was continued till the patient's lung functions were nearly equal to the levels before pregnancy. The benefits of short- and long-term intermittent nocturnal therapy have been previously reported as improvement in lung vital capacity, muscle strength, daytime oxygenation, exercise capacity, and pulmonary hypertension in restrictive lung diseases.[8],[9]

Echocardiography was done to know pulmonary hypertension for which sildenafil was administered. Sildenafil has emerged as an effective first-line oral therapeutic agent for pulmonary hypertension (PAH). It is a phosphodiesterase type 5 inhibitor that has an expanding role in the treatment of PAH. It improves mean pulmonary arterial pressure, pulmonary vascular resistance, cardiac index, and exercise tolerance.[10]

Other components of critical care which deem crucial in pregnant patients such as left lateral position, early feeding, input-output charting, regular ABG analysis, and weaning trials as soon as feasible, obstetrician checkups for fetal well-being helped in a successful outcome in this patient. Chopra et al.[11] in their review of 22 pregnant patients having kyphoscoliosis found that though the cesarean section was high; however, no maternal and perinatal risks occurred.


  Conclusion Top


A case of pregnancy associated with cardiopulmonary compromise due to spinal deformities is described where a well-planned and meticulous approach helped in a successful outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Menon B, Aggarwal B. Influence of spinal deformity on pulmonary function, arterial blood gas values and exercise capacity in thoracic kyphoscoliosis. Neurosciences 2007;12:293-8.  Back to cited text no. 1
    
2.
Banerjee B, Subedi S, Chhetri NBG, Gupta Y. Challenges in the caesarean section of a severely kyphotic parturient. Case Rep Obstet Gynecol 2016;2016:8405052.  Back to cited text no. 2
    
3.
Rousalova I, Vlachova A, Korbelar P, Patlejchova L, Andel M. A successful pregnancy in a woman with severe idiopathic kyphoscoliosis: A case report. Eur Respir J 2016;48:PA2206.  Back to cited text no. 3
    
4.
Kahler CM, Hogl B, Habeler R, Brezinka C, Hamacher J, Dienstl A, et al. Management of respiratory deterioration in a pregnant patient with severe kyphoscoliosis by noninvasive positive pressure ventilation. Wein Klen Wochenschr 2002;114:874-7.  Back to cited text no. 4
    
5.
Korula S, Ipe S, Abraham S. Parturient with severe kyphoscoliosis: An anesthetic challenge. J Obstet Anaesth Crit Care 2011;1:81-4.  Back to cited text no. 5
  [Full text]  
6.
Kim TH, Lee HH, Chung SH, Hwang SC, Kim JM. Woman giving birth with kyphoscoliosis, spinal cord injury and placenta praevia: A case report. J Med Cases 2012;3:264-6.  Back to cited text no. 6
    
7.
Gupta S, Singariya G. Kyphoscoliosis and pregnancy – A case report. Indian J Anaesth 2004;48:215-20.  Back to cited text no. 7
  [Full text]  
8.
Gonsalez C, Ferris G, Diaz J, Fontana I, Nunez J, Marin J. Kyphoscoliotic ventilator insufficiency: Effects of long term intermittent positive pressure ventilation. Chest 2003;124:857-62.  Back to cited text no. 8
    
9.
Adıgüzel N, Karakurt Z, Güngör G, Moçin Ö, Balcı M, Saltürk C, et al. Management of kyphoscoliosis patients with respiratory failure in the intensive care unit and during long term follow up. Multidiscip Respir Med 2012;7:30.  Back to cited text no. 9
    
10.
Barnett CF, Machado RF. Sildenafil in the treatment of pulmonary hypertension. Vasc Health Risk Manag 2006;2:411-22.  Back to cited text no. 10
    
11.
Chopra S, Adhikari K, Aggarwal N, Suri V, Sikka P. Kyphoscoliosis complicating pregnancy: Maternal and neonatal outcome. Arch Gynecol Obstet 2011;284:295-7.  Back to cited text no. 11
    


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