Acute Respiratory Distress Syndrome in

Pregnancy and Peripartum: Facts and Figures

Introduction
Patients are at Noncardiogenic
risk from many pulmonary
conditions edema caused by
specific to the capillary leak
pregnancy or and resulting in
other preexisting increased total
diseases lung water
Maternal
hypoxemia and
hypercapnia will One of the critical
pose significant illnesses of
risk for both Acute pregnancy and
mother and the respiratory peripartum
fetus distress period
syndrome
(ARDS)

This review discuss ARDS in pregnancy and peripartum period in the following headings:

• Physiological changes in pregnancy

• Etiology of acute respiratory failure and ARDS in pregnancy and peripartum period
• Definition and Diagnosis of ARDS in pregnancy
• Management of ARDS in pregnancy
• Outcome of ARDS in pregnancy.
Physiological changes In Pregnancy

Pregnant patients have decreased oxygen reserves while the oxygen demands
are increased

Parameters Changes
Residual volume Decreased by 15%
FRC Decreased by 20%
Expiratory reserve volume Decreased by 25%
Inspiratory reserve volume Increased by 5%
Inspiratory capacity Increased by 15%
Tidal volume Increased by 45%
Total lung capacity Decreased by 5%
Vital capacity No change
Closing capacity No change
FEV1 No change
FEV/FVC No change
Chest becomes barrel-shaped
Foetal oxygen delivery and determinants of
uterine oxygen delivery
Foetal oxygen delivery
Determinants of uterine oxygen
delivery
• Maternal PaO
• Hemoglobin concentration &
saturation
• Alkalosis causing leftward shift
of oxyhemoglobin dissociation
curve which increases O2
affinity and decreases O2
transfer
• Uterine artery blood flow
• Cardiac output
• Hypotension and/or increased
endogenous or exogenous
sympathetic stimulation.
Etiology of acute respiratory failure and acute
respiratory distress syndrome in pregnancy and
peripartum
Aetiology Types
Pregnancy related ARDS due to chorioamnionitis
ARDS related to placental abruption
Amniotic fluid embolism
Tocolytic-associated pulmonary edema
Peripartum cardiomyopathy induced pulmonary edema
Pulmonary edema due to preeclampsia

Increased risk in pregnancy Venous thromboembolism and pulmonary embolism

Gastric acid aspiration
Asthma
ARDS due to sepsis
Viral Pneumonia

Other conditions Pancreatitis

Drugs/toxins
Acute chest syndrome in sickle cell disease
Trauma
Etiology of acute respiratory failure and acute
respiratory distress syndrome in pregnancy and
peripartum
Pregnancy associated factors
Chorioamnionitis
• At onset of labor or with rupture of ovular membranes, bacteria
from the lower genital tract could ascend into the amniotic cavity
 most common pathway
• Although it is the common cause for sepsis in peripartum period, it
rarely complicates into ARDS
Placental abruption
• Separation of normally implanted placenta after 20 weeks of
gestation and before birth of fetus
• Frequently associated with massive blood and blood product
transfusion and may lead to ARDS
Amniotic fluid embolism
• Occurs in around 7/100,000 pregnancies, commonly associated with
labour and delivery or manipulation of uterus
• Frequently manifested by severe dyspnea and hypoxemia,
convulsions, and cardiovascular collapse and cardiac arrest
Etiology of acute respiratory failure and acute
respiratory distress syndrome in pregnancy and
peripartum
Increased risk in pregnancy

Transfusion related acute lung injury

• Massive transfusion of blood and blood products lead to transfusion related

acute lung injury (TRALI)
• TRALI is previously known as “transfused ARDS” because of the same
pathognomonic features, but associated with plasma transfusion
Pulmonary embolism
• The risk is increased five‐to six‐times during pregnancy
• A consequence of several factors: changes in the clotting factors and an
increased likelihood of venous stasis.
• Predisposing factors: obesity, older age, and a personal or family history of
thromboembolic disease, inherited thrombophilia, anti-phospholipid syndrome,
trauma, caesarean delivery, and immobility.
Etiology of acute respiratory failure and acute
respiratory distress syndrome in pregnancy and
peripartum
Increased risk in pregnancy

Pulmonary aspiration
• Common during labor or immediate postpartum period
• Effects of sedation, analgesia, increased intra-abdominal pressure.
• Risk factors: increased intra-abdominal pressure, relaxation of the
lower esophageal sphincter, and delayed gastric emptying

Asthma and its exacerbation

• Prevalent among 4%–8% of pregnant patients, and 20%–36% of them
have an exacerbation during their pregnancy

Pneumonia
• Community-acquired pneumonia is a common cause of acute
respiratory failure in pregnant patients.
• Reduction in cell-mediated immunity associated with pregnancy also
predisposes women
Etiology of acute respiratory failure and acute
respiratory distress syndrome in pregnancy and
peripartum
Increased risk in pregnancy

Pulmonary aspiration
• Common during labor or immediate postpartum period
• It may be the effects of sedation, analgesia, increased intra-abdominal pressure.
• Risk factors: increased intra-abdominal pressure, relaxation of the lower
esophageal sphincter, and delayed gastric emptying
Sepsis
• Incidence: 0.1% - 0.3%
• Risk factors: advanced maternal age, obesity, insulin-dependent diabetes
mellitus, multiple pregnancies, invasive diagnostic or therapeutic interventions.
• Incidence of peripartum sepsis is 3 times higher in preterm deliveries than in full
term deliveries.
• Intra‐amniotic infection is a significant predisposing factor
• Postpartum sepsis is reported to be 3 times more common after the lower
segment caesarean section than vaginal delivery
Etiology of acute respiratory failure and acute
respiratory distress syndrome in pregnancy and
peripartum
Conditions causIng acute respiratory distress syndrome in pregnancy

Acute pancreatitis
• Annual incidence: 1 in 1000 to 1 in 10,000, more frequent in 3rd trimester
• Risk factors: advancing gestational age and frequency of gallstones in pregnancy

Trauma
• Most common: assaults, motor vehicle accidents, falls, and partner abuse

Acute chest syndrome

• Pregnancy can be associated with sickle cell disease and those patients are at
risk of developing acute chest syndrome
Definition and diagnosis
Characteristic AECC definition 1994 Berlin Definition 2012
Timing Acute,No specific time given Maximum within a week after a trigger insult
Imaging Chest X-ray with bilateral Chest X‐ray or CT scan with bilateral infiltrates, not
infiltrates fully explained by effusion, lung collapse or nodules
Noncardiogenic Confirmation of nonelevated Respiratory failure not completely explained by
source of edema left atrial pressure excessive volume loading or cardiac failure
Classification Based on PaO2/FiO2 Based on PaO2/FiO2 with PEEP ≥5 cmH2O
Acute lung injury: ≤300 Mild: 201-300
ARDS: ≤200 Moderate: 101-200
- Severe: ≤100

Predisposing Not specified If none identified, then need to rule out hydrostatic
condition edema with additional data like Echocardiogram or
other hemodynamic parameters
Definition and diagnosis

Computerized tomography chest showing bilateral

Chest X‐ray showing bilateral patchy infiltrates patchy consolidations

Investigation Maternal Foetal radiation Maternal and foetal risk of radiation

breastexposure exposure (mGy)
(m Gy)

Chest radiograph 0.2 0.010 Lesser risk to foetus

Ventilation-perfusion <1.5 0.20-1.0 Lesser exposure to maternal breast
scan
CT chest/angiogram 10-18 0.1-0.8 Significant exposure to maternal breast
 Management

Acute respiratory distress syndrome 12

1. Lower tidal volume (lung protective strategy)
2. Higher respiratory rate
3. PEEP titration
4. Negative fluid balance
5. Neuromuscular blocking agents
6. Prone position
7. Inhaled nitric oxide
8. High frequency oscillation
9. ECMO
10. ECCO2R
11. Corticosteroids
12. Supportive care

ECMO: Extracorporeal membrane oxygenation, ECCO2R: Extracorporeal carbon dioxide removal,

PEEP: Positive end expiratory pressure
 Management

Goals: oxygen saturation >95%, arterial oxygen tension (PaO2) >70

mmHg

Standardized mechanical ventilation

• Lung protective strategies, include lower tidal volume (6 ml/kg), increasing

the respiratory rate
• Driving pressure (plateau pressure-PEEP) is considered to be more
important than tidal volume and plateau pressure and worth monitoring
• Special considerations in pregnant patients include:
• A higher SpO2 as adequate foetal oxygenation requires PaO2 70 mmHg
• A lower PaCO2 target of 30–32 with mild respiratory alkalosis
• A higher PEEP to mitigate the atelectasis induced by gravid uterus.
 Management

Negative fluid balance

• Restricting fluid intake and keeping the fluid balance negative, patients will benefit
from decreased lung water content.
• Though it had not shown any beneficial effect on mortality, it resulted in more days
free from mechanical ventilation and ICU stay

Neuromuscular blocking agents

• Might improve the mechanical viscoelastic properties of chest wall.
• Prolonged use of NMBA particularly in combination with steroid will increase the
chances of critical illness neuromuscular abnormality.

Prone Positioning in pregnancy

• Ventilation in prone position improves oxygenation in all the patients by reopening
the posterior dependent consolidated areas of the ARDS lungs

Inhaled nitric oxide (iNO)

• Cannot be recommended for the general management of ARDS in pregnancy

High frequency oscillation

• Mechanical ventilation that uses the lung protective benefits of very low tidal
volumes less than anatomical dead space combined with very high respiratory rates
 Management

Extracorporeal membrane oxygenation

• Overall maternal survival as 80% and fetal survival as 70%
• Technically challenging, bleeding was common leading to large volumes of blood
transfusion which contributed largely to the mortality

Extracorporeal carbon dioxide removal

• Mainly targets the removal of CO2 only

Corticosteroids
• Used by clinicians in 3 different situations:
• Prevention of ARDS in high risk patients
• Early treatment of ARDS with high-dose and short-course therapy,
• Prolonged therapy in unresolving ARDS

Supportive care
• Includes sedation, pain control, hemodynamic support (vasopressors), monitoring of
vital signs, adequate volume management, nutritional support, stress ulcer
prophylaxis, and venous thromboembolism prophylaxis.

Outcome
• Mortality is comparatively lower and reported to be 9%, and the risk factors are
prolonged ventilation, renal failure requiring dialysis, liver failure, amniotic fluid
embolism, influenza and septic obstetric emboli
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