Acute respiratory distress in a twin pregnancy : a case report

When multiple obstetric complications come together in a pregnant patient with undocumented non-obstetric comorbidities, a sudden and unexpected clinical presentation may dramatically change the therapeutic strategy. We describe the case of a 35-yr-old primigravid woman with a twin pregnancy who developed severe acute respiratory distress at 32 weeks of gestation during hospitalization for the indication of a cervical shortening. She received tocolytics and corticosteroids for fetal lung maturation and presented signs of mild pre-eclampsia during hospitalization. Because maternal condition worsened despite supportive measurements, an emergency caesarean section was performed under general anesthesia. Postoperatively, echocardiography revealed a previously unknown mitral valve insufficiency, which was thought to be chronic as stable findings were observed 4 weeks postpartum. The presence of pre-eclampsia in a patient with chronic mitral valve insufficiency and the use of a combination of betamethasone and tocolytic treatment were thought to be the triggering factors for the dramatic worsening of her hemodynamic status. Due to the rising incidence of risk factors for preterm delivery and pre-eclampsia situations, in which the combination of tocolysis and fetal lung maturation is indicated, such a complication might theoretically become more frequent. As illustrated by our case, this can complicate management and may unexpectedly result in cardiopulmonary decompensation during pregnancy. A multidisciplinary approach is needed to insure an optimal outcome for the mother and the child. When treatment with a combination of tocolytics and corticosteroids is indicated in a pre-eclamptic patient, a diagnostic echocardiography and continuous monitoring of arterial oxygen saturation with pulse oximetry should be considered.