Case report

A Rare Case of Acute Respiratory Failure in Pregnancy

Melia Budi Astuti, Lisna Rosalia Agaus

General Practitioner, Siloam Hospitals Buton, Baubau, Indonesia.
meliabudiastuti@gmail.com, lisna.raffaza@gmail.com,

ABSTRACT
Anatomical and physiological changes during pregnancy increases susceptibility to respiratory
failure. Respiratory failure during pregnancy is rare. Pulmonary sepsis is one of the main cause
of maternal deaths due to respiratory failure. A case of 35 years old female, G5P4A0 at 33-34
weeks of gestation presented with hypoxemic respiratory failure. The patient ventilated by Non-
Invasive Ventilation (NIV) method for 6 days. The patient and her baby were discharged from
hospital after 14 days in good condition.
Keywords: acute respiratory failure, hypoxemic, NIV, pregnancy, sepsis.

ABSTRAK
Perubahan anatomi dan fisiologis selama kehamilan meningkatkan kerentanan terhadap kejadian
gagal nafas. Gagal nafas akut selama kehamilan jarang terjadi. Sepsis pulmonal menjadi salah
satu penyebab utama kematian ibu akibat kegagalan pernafasan. Kasus seorang wanita 35 tahun,
G5P4A0 pada usia kehamilan 33-34 minggu mengalami kegagalan pernapasan hipoksemia.
Pasien diventilasi dengan metode ventilasi non-invasif (NIV) selama 6 hari. Dia dan bayinya
dipulangkan dari rumah sakit setelah 14 hari perawatan di rumah sakit dalam kondisi baik. Melia
Budi Astuti, Lisna Rosalia Agaus . Gagal Napas Akut pada Kehamilan. Laporan Kasus
Kata kunci : gagal nafas akut, hipoksemia, kehamilan, NIV, sepsis.

INTRODUCTION
The incidence of respiratory failure in pregnancy is estimated 0,1% to 0,2% with high mortality
rates up to 40%.1,2 Reports of acute respiratory failure as a cause of maternal mortality are
limited, particularly in developing countries such as Indonesia. Early identification of patients at
risk for acute respiratory failure is necessary to reduce maternal mortality.1
CASE REPORT
A 35 year-old, G5P4A0, at 33-34 weeks of pregnancy complained shortness of breath with
history of fever and productive cough with bright red phlegm for the past 4 days before
admitted to the hospital. No history of dysuria, smoking, and cardiovascular disease.
On examination she was conscious and oriented, dyspneic with blood pressure (BP) of 110/60
mmHg, heart rate (HR) 113x/minute, temperature 38,3ºC, respiratory rate (RR) 36x/minute with
oxygen saturation (SaO2) 83% on room air. Auscultation revealed subcostal retraction and
bronchial breath sounds with coarse rales in all lung fields. Cardiac examination was within
normal limit. An obstetric ultrasound examination showed a normal viable fetus at 33-34 weeks
of gestation and no signs of fetal distress monitored by cardiotocography (CTG). Laboratory
examination revealed haemoglobin (Hb) 10,1 mg%, platelet (PLT) 133.000/ µL, white blood
cell (WBC) 4.160 µL, neutrofil 75, lymphosit 18. Slightly elevated aspartate aminotransferase
(AST) 78 IU/L and alanine transaminase (ALT) 37 IU/L. Result of urinalysis were unremarkable
except, urubilinogen (+4). Artery blood gas analysis showed PH 7,404; PaO2 47;PCO2 24,2;
BE -7,8; and HCO3 14,8 on room air. A chest radiography showed bilateral diffuse consolidation
consistent with pulmonary edema and pneumonia (Figure 1). Echocardiography examination
showed a normal left ventricular function with an ejection fraction 67%, no findings suggestive
of valvular disease or cardiomyopathy.

Figure 1. Thorax X ray

 She was diagnosed with hypoxemic acute respiratory failure due to suspected pulmonary sepsis
with pulmonary edema. SaO2 was improving when we initiated of oxygen 10 lpm via non
rebreathing mask (NRM). The patient had given intravenous ceftriaxone and admitted to the ICU
for close monitoring.
After 6 hours in the ICU, signs of fetal distress detected by CTG, urgent caesarean section was
decided to terminate the pregnancy. The baby was successfully delivered and had APGAR scores
of 2 and 8. During caesarean section, SaO2 of 81% on 15 lpm O2 via NRM, hence invasive
ventilation was started to maintain adequate oxygenation. Back in the ICU, she was self-
extubated. Ventilation was continued with NIV with SIMV PEEP 8, VT 370, RR 12x/m, FiO2
100% then SaO2 improved up to 99%. Intravenous ceftazidime and ciprofloxacin (dose ?) were
given, replaced with intravenous meropenem (dose ?) after two days as there was no clinical
improvement. She was successfully weaned from NIV after 6 days of ventilation and shifted to
the general ward. She and her baby were discharged home after 14 days of hospitalization in
good condition.

DISCUSSION
Inability of the respiratory system to maintain adequate gas exchange or adequate ventilation due
to pulmonary or extra-pulmonary condition may produce hypoxemic (type 1) or hypercapnic
(type 2) respiratory failure.2,3 Acute respiratory failure during pregnancy is rare but it is often
requiring ICU admission.3 Etiologies of respiratory failure in pregnancy divided into three causes
: hypoxemic respiratory failure associated pregnancy, hypoxemic respiratory failure non
associated pregnancy, and hypercarbic respiratory failure (see table 1).4
Our case was diagnosed as type 1 hypoxemic respiratory failure due to non-pregnancy causes
specifically due to suspected pulmonary sepsis. Diagnosis was based on blood gas analysis
showed low level of oxygen in the blood (PaO2 47 mmHg), without increased level of carbon
dioxide in the blood ( PCO2 24,2 mmHg).

Table 1. Etiologies of Respiratoty Failure. 1,2

1 Hypoxemic respiratoy failure: AFE

pregnancy specific Pulmonary edema secondary to tocolytics
Pulmonary edema secondary to
preeclampsia/eclampsia
Cardiogenic pulmonary edema secondary to
peripartum cardiomyopathy
ARDS secondary to placental abruption,
obstetric hemorrhage, chorioamnitis, or
endometritis.
2 Hypoxemic respiratory failure: Aspiration pneumonia / pneumonitis
Non pregnancy Viral/bacterial pneumonia
Pulmonary embolism
Venous air embolism
Cardiogenic pulmonary edema secondary to
 heart failure unrelated to pregnancy
Atelectasis
Pneumothorax
ARDS secondary to transfusion-associated
acute lung injury, pulmonary contusion, sepsis,
trauma, burns.
3 Hypercarbic respiratory failure Reactive airway disease/asthma
Drug overdose
Neuromuscular disorders : myasthenia gravis,
guillan-barre

Sepsis and pneumonia are the leading non-pregnancy cause for respiratory failure in pregnancy .5
Sepsis is a systemic inflammatory response to a confirmed or suspected infection.6 Blood
cultures are the clinical gold standard for the diagnosis of sepsis due to bacterial infections.7
Systemic Inflammation Response Syndrome (SIRS) is the occurrence of at least two of following
criteria : fever >38,0ºC or hypothermia <36ºC, tachycardia >90 beats/minute, tachypnea >20
breaths/minute, leucocytosis>12 ARDS*109/l or leucopoenia <4*109/l.6 Bacterial sepsis is
characterized by increased neutrophil to lymphocyte count ratio which useful as a marker of
sepsis, while the total white blood cell count is poor predictors of sepsis.7 It was proven in initial
laboratory result revealed neutrophilia and lymphocytopenia but there was no increased white
blood cell count (see table 2). A significant increased in WBC observed after 3 days of the
hospital admission from 4.160mg/dl to 19.890 mg/dl (see table 2). Blood culture could not be
performed in this case due to limited resources. However suspected due to sepsis based on
clinical manifestations, and laboratory findings included fever, tachycardia, leukocytosis,
neutrophilia, lymphocytopenia, and clear source of infection that identified from history taking.
She had history of fever, productive cough, and shortness of breath with abnormal chest
radiograph. The findings led to diagnose suspected pulmonary sepsis .

Table 1. Complete Blood Count Time-line

24/7/2017 25/7/2017 26/7/2017 29/7/2017 31/7/2017 NORMAL

VALUE
(admission) 2nd day 3rd day 6th day 8 th day
Hb 10,1 12,2 12,3 13,3 13,7 11,7-15,5
(g/dL)
WBC 4.16 7,67 19,89 19,45 14,52 3,6-11,0
(103 /ul)
PLT (103 133 167 301 438 522 150-440
/ul)
Neutrofil 75 84 79 83 79 50-70
(%)
 Limfosit 18 12 10 7 5 20-40
(%)

Delivery of the fetus should be considered if it give benefit to the fetus, despite it does not
always improve maternal respiratory function.2 Signs of fetal distress was identified by CTG
monitoring. Two doses of early intravenous dexamethasone had given to prevent respiratory
distress syndrome in the neonate.8 Termination of pregnancy by urgent ceaseran section should
be performed and successfully delivered a viable female baby.
Administration of antibiotics regimen should be given based on microbiological culture result,
but it could not be performed due to limited resources. However, antibiotic regimen
consideration based on empiric treatment of pneumonia as underlying disease and clinical
response in the patient. Patient’s condition showed improvement after day 5th of administration
intravenous meropenem.
Approximately 41% of criticall ill pregnant women develop respiratory failure requiring
mechanical ventilatory support.9 NIV is one of ventilation methode which suited to short-term
ventilator support with benefits can avoid the potential complication of endotracheal intubation
and the associated sedation.9 NIV only be used in the pregnant patient who is alert and able to
protect her airway.2 She was successfully weaned from NIV after 6 days of ventilation and
discharged home with her baby after 14 days of hospitalization in good condition.

CONCLUSION
ARF during pregnancy is a critical condition that requires intensive care treatment. Physiological
changes due to pregnancy complicated with sepsis can cause maternal and fetal death. Prompt
diagnosis of ARF and initiation of appropriate therapy can decrease the mortality rate. Intensive
care management of the patient may require a multidisciplinary approach involving obstetricians,
cardiologist, internist, and anesthesiologist consultants. NIV is essential in management of ARF
in this patient. Early assessment of signs fetal distress and plan of delivery are crucial to optimize
both maternal and fetal outcomes.

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