Acute Respiratory Distress after Cesarean Section<br />Mostafa Mohammadi M.D.**<br />Mohammed sasaa AL- mosawi MSc. Anaesthesia* Ali zaidan Alomaran MSc. Anaesthesia *<br />** Anesthesiologist, Intensivist, TUMS, corresponding auther<br />*Anesthetist and lecturer at AL-Mustaqbal College University <br /><br /><br /><br />Introduction<br />Dyspnea during pregnancy and in the immediate postpartum or postoperative period is a relatively common problem that can create a threatening condition for mother and neonatal (2). Acute respiratory distress after delivery is a common problems is that it can have a wide range of p the differential of patients with dyspnea following delivery (3).<br />Cardiac problems such as cardiac tumors can be the first factor that doctors suspect with an overall incidence of less than 0.2% (4). Pulmonary edema could be next suspicions factor (5). The progression of pulmonary edema may quickly leads to pulmonary dysfunction and is put the life of the pregnant woman and her fetus in danger (6). During pregnant, pulmonary edema is commonly comes along with tocolytic therapy, infection, preeclampsia, preexisting cardiac disease and fluid and blood replacement therapy (7-10).<br />Case presentation<br />A 38-year-old woman, PG, with thrombocytopenia that the routine tests during pregnancy showed positive Lupus anticoagulant, anti.ph, anti-cardiolipin (IgM),<br /> <br />Negative anti ds DNA and suspicious signs of butterfly rash has been selected for recording the information and publishing in a case report. Pre-operation rheumatologist consultant resulted the negative history and absence of positive clinical and para-clinical findings so rheumatologic disease is currently not considered and the consultant with hematologist has been advised that the result of this consultant could be seen in table 1.<br /><br />Table 1: The Result of Hematologist Test before Starting the Treatment<br /><br /> Values<br />WBC 11900<br />HB 10.6<br />Plt 86000<br />PH 7.4<br />PO2 71.8<br />PCO2 28.7<br />HCO3 18<br />PT 11<br />INR 1<br />PTT 25<br />BS 70<br />Urea 32<br />Cr 0.9<br />Na 134<br />K 3.9<br />AST 21<br />ALT 6<br />ALP 428<br />BIL NL<br />LDH 449<br /> <br />The cesarean delivery performed in a stable situation with liquid treatment with 2000ml crystalloid and the patient had no symptoms or complains of dyspnea during delivery operation and the mother left the operation room in stable condition at 00.10 AM. Post-operative rheumatologic counseling showed a stable situation of the mother and the rheumatologist requested inflammatory indices and lupus markers once again and advised to visit at rheumatology clinic.<br />After receiving 2500ml crystalloid in ward because of decreasing U/O, the patient starts to show dyspnea and respiratory distress after 1 AM. Also patient showed the crackles (rales) spreads across the lungs, which is mostly on the right beside cough, hemoptysis and dropping SPO2.<br />Emergency cardiac advice was given that result showed sinus tachycardia (PR = 120),<br />BP: 110/70, SPO2: 87%. So, 100 mg Lasix infusion administrated and continued with potassium checking. Bedside echo chest X-ray image (Figure 1) showed EF = 50% and we requested for an internal medicine and anesthesiology consultant for Brain Natriuretic Peptide (BNP) and Troponin Tests.<br /><br /><br />Figure 1: Chest X-Ray Image of the Patient<br /> <br />Consultant of Internal medicine at 02:00 AM resulted to treatment of pulmonary edema, Hydrocortisone, CT angiography, Bronchodilator and routine tests. These treatments resulted that at 04:30 AM despite oxygen intake the SPO2 is 84%. Crackles is decreased but patients has hemoptysis so emergency CT angiography and intubation consultant requested. The anesthesiologist consultant at 05:00 AM also resulted to intubation and transferrin the patient to general ICU. Rheumatologist at 06:00 AM decided to administration an anti-coagulation and also Due to the lack of adequate data for the diagnosis of lupus, an urgent emergency test is to be performed. The patients has been transferred to ICU ward at 06:30 AM and echo-cardiograph performed on her at 08:30 AM that showed EF 50%, Nl LV size & mild LV dysfunction, Mod RV Enlargement, Mod MS & MR, Mild AS & mod AI, mod TR and TRG 45 &PAP 50. So Lasix infusion were continued and 25 mg Methoral administrated.<br />Rheumatologist consultant at 10:00 AM resulted that despite the lack of adequate diagnostic data for lupus or anti-phospholipid and receiving antibiotics by the patient and R/O PTE, corticosteroids is administrated and according to clinical situation of the patients some decision should be take about plasmapheresis and PBS survey to make sure about schistocytes.<br />Pulmonary consultant at 12:00 PM resulted that the pulmonary artery trunk and IVC is dilated, and there is evidences of chronic rheumatic disease and hypertension (HTN). All symptoms lead us to pulmonary edema, however, the possibility of alveolar hemorrhage cannot be ignored so we continue on wide AB, corticosteroids, Lasix and bronchoscopy.<br />Cardiologist consultant showed that pulmonary crackles were decreased and SPO2 = 94% and in the case of changing hemodynamic conditions Three-valve Emergency Surgery should be performed.<br />Hematology consultant at 07:30 PM resulted to absence of plasmapheresis indication and platelet injection and no schistocytes detected after twice PBS. Hemodynamic conditions of the patient was stable during the day and treatments with corticosteroids, Lasix, heparin, Meropenem, Vancomycin and Ciprofloxacin were continued.<br /> <br />After a counseling meeting with ICU attends, Pulmonologist, Rheumatologist, Gynecologist, Cardiac surgeon and radiologist decided to starting the plasmapheresis weaning and extubation beside previous treatments.<br />After stabilizing the patient condition we have stopped the heparin and also methylprednisolone has been changed to dexamethasone and peripheral blood smear (PBS) that showing thrombocytopenia was not found (Figure 2). Also hematology test after treatment could be seen in Table 2.<br /><br />Table 2: The Result of Hematologist Test after the Treatment<br /><br /> Value<br />WBC 13000<br />Hb 11.3<br />Plt 38000<br />CRP 29<br />Lactate 8.9<br />Lupus.anti,c Pos<br />CH50 Pos<br />Anti-RO Neg<br />Procalc. Neg<br />BS 125<br />Na 134<br />K 3.4<br />Cr 0.8<br />AST 19<br />ALT 10<br />PTT 25<br />INR 1.8<br />Ca 8<br />P 3<br />Alb 3.5<br /> <br />PH 7.51<br />PCo2 37<br />po2 97<br />Hco3 28<br />u.p.24 743<br /><br /><br /><br />Figure 2: The Chest X-Ray Image of the Patient after Receiving the Treatments<br /><br /><br />The patient's respiratory conditions were significantly improved at the next day and the patient's platelet level were raised and finally the patients transferred to the ward in a stable condition and continued with administration of AB and dexamethasone.<br /><br /> DISCUSSION<br />Improvement in practice medicine have made it reasonable for women subordinate medical situation or with progress maternal age to conceive and hold a fetus to term. This has produce to an augmentation in count of women need maximal attention pre and post Cesarean periods.<br />There are various intense complications particular to pregnancy that, although infrequent, need a rise level of proficiency and awareness for favorable management. (11). The reasons for shift to general medical ICU embrace directness mechanical ventilation. (12)<br /> <br />Acute respiratory distress (ARD) is a serious cause of morbidity and death rate through the pregnant. (13). The clinical syndrome of Acute RDS is differentiate by damage to the alveolar- capillary barrier produce in alveolar flooding and hypoxemia. (14)<br /><br />The main driving reasons of acute respiratory distress are infection , hemorrhage, aspiration , preeclampsia and low platelet , pulmonary edema ordinarily appear an eventual widespread passageway of multiple of these above complication of pregnancy and peripartum period.(15, 16)<br />The proportion of pregnancies which are convoluted by intense pulmonary edema has been notified to be 0.08 %.( 16)<br />The doctors have constantly estimated the grade of leucocytosis in Patients with pneumonia as a sign of systemic inflammatory Response acuteness of disease.<br /><br />Thrombocytopenia as well renowned record holder of poor outcome in patients with pneumonia, because of the combination of minimum platelet counts with DIC with acute sepsis. (17). Platelets are influential inflammatory cells that can endure chemotaxis and are capable to shot numerous pro inflammatory molecules.<br />There is a considerable parentage between the coincidence respiratory complications and thrombocytopenia. (18)<br /><br />So in our case by take away the cardiogenic cause for pulmonary edema by ECO and the non-cardiogenic cause's possible amniotic fluid embolism also.<br /><br />References<br />1. Matthay MA, Ware LB. Plasma protein C levels in patients with acute lung injury: prognostic significance. Critical care medicine. 2004;32(5):S229-S32.<br />2. Adler C, Jesus J, Reuter H. [Acute dyspnea 8 days after Cesarean section]. Med Klin Intensivmed Notfmed. 2016 Sep;111(6):544-6. PubMed PMID: 26440100. Akute Dyspnoe 8 Tage nach Sectio caesarea.<br />3. Wyman A, Hurd W, Lappen J. Cardiac myxoma presenting as dyspnea after cesarean delivery. Case Rep Med. 2012;2012:487385. PubMed PMID: 22778750. Pubmed Central PMCID: PMC3384962.<br /><br /> <br />4. 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