Management of Acute Chest Syndrome in Pregnant Patients
The treatment of acute chest syndrome (ACS) in pregnant patients should include prompt oxygen therapy, intravenous fluids, antibiotics, pain management, incentive spirometry, and consideration of blood transfusion therapy, with care provided in a multidisciplinary setting involving hematology and maternal-fetal medicine specialists.
Pathophysiology and Diagnosis
- Acute chest syndrome is a life-threatening complication of sickle cell disease characterized by fever, respiratory symptoms, and new pulmonary infiltrates on chest imaging 1
- The pathophysiology involves vaso-occlusion in pulmonary vessels resulting in hypoxia, inflammation, acidosis, and lung tissue infarction 1
- Common precipitants include infections (viral or bacterial), rib infarction, and fat emboli 1, 2
- Diagnostic criteria include a new infiltrate on pulmonary imaging combined with fever >38.5°C, cough, wheezing, hypoxemia, tachypnea, or chest pain 1
Initial Management
- Immediate oxygen therapy should be administered to achieve arterial oxygen saturation ≥95%, using non-invasive ventilation with PEEP if necessary for severe hypoxemia 3
- Judicious intravenous fluid administration is essential to maintain hydration while avoiding fluid overload 2, 4
- Aggressive incentive spirometry and pulmonary toileting should be implemented to prevent atelectasis 2, 4
- Pain management with appropriate analgesics is crucial, but careful monitoring is needed as opiate overdose and resulting hypoventilation can trigger or worsen ACS 4
Antibiotic Therapy
- Broad-spectrum antibiotics should be administered after obtaining blood cultures, as infection is a common precipitant of ACS 2, 1
- Antibiotic coverage should address common respiratory pathogens including atypical organisms 2
Transfusion Therapy
- Blood transfusion should be considered to increase oxygen-carrying capacity and reduce complications by decreasing hemoglobin S percentage 5
- For severe cases with respiratory failure or neurologic symptoms, exchange transfusion may be preferred over simple transfusion to rapidly reduce HbS levels while avoiding volume overload 2, 5
Special Considerations in Pregnancy
- Pregnancy creates additional physiologic stress with increased blood volume, cardiac output, and oxygen demand, which may complicate ACS management 6
- Left uterine displacement should be maintained during management to prevent aortocaval compression by the gravid uterus 6
- Continuous monitoring of maternal oxygenation and fetal heart rate is essential 6
- Ventilation volumes may need to be reduced due to the elevated maternal diaphragm in pregnancy 6
Bronchodilator Therapy
- Bronchodilators should be administered if there is a history of asthma or evidence of bronchospasm 2, 4
- Beta-1 selective blockers are preferred during pregnancy if needed for other indications 6
Monitoring and Escalation of Care
- Close monitoring for clinical deterioration is essential, with low threshold for ICU admission 1
- Mechanical ventilation may be required in cases of respiratory failure, with approximately 13% of ACS patients requiring this intervention 2
- Continuous invasive hemodynamic monitoring should be considered in critically ill pregnant patients 3
Delivery Considerations
- For stable patients with well-controlled condition, spontaneous vaginal birth is preferable 3
- Planned cesarean section should be considered for critically ill women requiring inotropic therapy or mechanical support 3
- Epidural analgesia is preferred during labor as it stabilizes cardiac output 3
- Avoid prolonged bearing down efforts; consider assisted vaginal delivery to shorten the second stage 3
Prevention of Recurrence
- Treatment with hydroxyurea should be considered for prevention of recurrent episodes after delivery 4
- Close follow-up is essential as most pregnancy-related complications occur in the first 4 weeks postpartum 3