The physiologic and hormonal stresses that occur during pregnancy and labor have the potential to worsen existing respiratory disease and can pose unique challenges in management for the obstetrician and obstetric anesthesiologist. Cases of respiratory disease in pregnancy require specific planning and management to optimize maternal and fetal outcome. This chapter discusses rare respiratory disorders that the obstetric anesthesiologist may encounter in practice: acute respiratory distress syndrome, cystic fibrosis, pneumothorax, status asthmaticus, thromboembolic disease, mediastinal mass, congenital central hypoventilation syndrome, pulmonary lymphangioleiomyomatosis, restrictive and interstitial lung disease, transfusion related acute lung injury, transfusion-associated circulatory overload and lung transplantation. The aim is to present relevant discussion in order provide the anesthesiologist with some background and evidence to support her/his decision-making when encountering these rare and challenging cases.

Acute pulmonary embolism (PE) carries a high risk of morbidity and mortality and has a wide spectrum of severity, from incidental diagnosis in an asymptomatic patient to sudden refractory shock and cardiovascular collapse. Although the exact incidence remains uncertain, it is estimated that approximately 600,000 patients are diagnosed with PE annually in the United States, with mortality rates as high as 30% for patients with hemodynamic instability at presentation. A high-risk PE is one associated with hypotension or bradycardia. An intermediate-risk PE has evidence of RV strain, either by imaging or biomarkers (troponin or BNP). All others are low-risk PEs. The diagnosis of PE is often complicated by presentations that can be subtle, atypical or confounded by another coexisting disease.

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

A 28-year-old nulligravida with known factor V Leiden mutation is referred by her primary care provider to your hospital center’s high-risk obstetrics unit for preconception counseling.

Key Learning Points

1. 1. The critical care population is at high risk of venous thromboembolism.

2. 2. Classification of pulmonary embolism is based on mortality risk.

3. 3. The clinical presentation of pulmonary embolism in the critical care environment is atypical and diagnosis remains difficult.

4. 4. Computed tomography pulmonary angiography is the investigation of choice for pulmonary embolism.

5. 5. Anticoagulation is the mainstay of acute treatment, with thrombolysis being reserved for high-risk pulmonary embolism.