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Detecting pulmonary edema in multiple pregnancy through point-of-care lung ultrasonography

  • J. Gu
    Affiliations
    Department of Anesthesiology, West China Second University Hospital, Sichuan University, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, Sichuan, China
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  • L.L. Luo
    Affiliations
    Department of Anesthesiology, West China Second University Hospital, Sichuan University, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, Sichuan, China
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Published:October 24, 2018DOI:https://doi.org/10.1016/j.ijoa.2018.10.008
      We managed a 29-year-old, gravida 1 para 0, woman at 32 weeks-of-twin-gestation who underwent emergent cesarean section for arrest of descent. She had been treated with ritodrine and dexamethasone for two days. At the operating room her body temperature was 38.5°C; blood pressure 130/85 mmHg; heart rate 125 beats-per-minute; respiratory rate 23 breaths-per-minute and oxygen saturation 95% on room air. General anesthesia was chosen because of the lack of a routine blood examination and our suspicion of systemic infection. Rapid sequence induction was with remifentanil, propofol and succinylcholine. After intubation her oxygen saturations decreased to as low as 82%, ranging from 89–95% with manual ventilation. The baby was delivered while the maternal inspired oxygen was 100%. Auscultation of her lungs revealed wheezing. The surgery lasted 40 minutes, the blood loss was 800 mL and the patient received one litre of crystalloid solution, associated with a urine output of 400 mL. After extubation, her lowest oxygen saturation was 88% on room air. Five hours later, in the intensive care unit, lung auscultation revealed bilateral rales and her pro-brain natriuretic peptide concentration was 1020 pg/mL. She was discharged after 10 days of treatment for infection and heart failure.
      Another 28-year-old, gravida 1 para 0, woman was scheduled for cesarean section at 35 weeks-of-twin-gestation for breech presentation. She had received tocolytic therapy with ritodrine and dexamethasone for 20 days. When she arrived in the operating room, lung ultrasonography revealed multiple B-lines, despite no abnormalities being heard on lung auscultation. Combined spinal-epidural anesthesia was performed and intravenous fluid volumes were restricted. Nevertheless, she complained of dyspnea after delivery and lung ultrasound showed the “rockets” sign in the lower lung fields. Intravenous furosemide was administered and her symptoms rapidly improved. She was sent to the ward and discharged two days later.
      Multiple pregnancy is a risk factor for pulmonary edema, which can be life-threatening and is a common reason for intensive care admission. Point-of-care lung ultrasonography is beneficial, as the anesthesiologist may be able to detect pulmonary edema early and make appropriate decisions. The maternal blood volume in twin pregnancy is about 400 mL more than a single pregnancy.
      • Pritchard J.A.
      Changes in the blood volume during pregnancy and delivery.
      Volume overload contributes to the development of pulmonary edema and after delivery, blood volume increases further following uterine contraction, potentially worsening pulmonary edema. These processes appeared apparent in our first patient, although ritodrine used for tocolysis may have been an additional contributor.
      • Shinohara S.
      • Sunami R.
      • Uchida Y.
      • Hirata S.
      • Suzuki K.
      Association between total dose of ritodrine hydrochloride and pulmonary oedema in twin pregnancy: a retrospective cohort study in Japan.
      Both our patients were treated with ritodrine.
      The diagnosis of pulmonary edema is primarily confirmed on chest radiography: lung auscultation has low sensitivity. In contrast, lung ultrasonography is a safe, effective and sensitive method of diagnosing pulmonary edema. In multiple pregnancy, a finding of three or more B-lines in a lung field is 86–93% sensitive and 93–98% specific for pulmonary alveolar interstitial syndrome.
      • Volpicelli G.
      • Caramello V.
      • Cardinale L.
      • Mussa A.
      • Bar F.
      • Frascisco M.F.
      Detection of sonographic B-lines in patients with normal lung or radiographic alveolar consolidation.
      • Volpicelli G.
      • Mussa A.
      • Garofalo G.
      • et al.
      Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome.
      Spinal anesthesia may be preferable when multiple B-lines are detected, as this may reduce venous return, but fluid restriction is also recommended. After delivery, lung ultrasonography can help in the early recognition and treatment of pulmonary edema. In our second patient, point-of-care lung ultrasonography proved valuable, so that pulmonary edema was not exacerbated. The patient avoided intensive care unit admission.
      In conclusion, multiple pregnancy with tocolytic treatment is a well-known risk for pulmonary edema. Point-of-care lung ultrasonography may a help detect pulmonary edema early and assist in making timely clinical decisions. Lung ultrasonography has the potential to improve the quality of care of women with multiple pregnancy.

      References

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