Rapid-Sequence Intubation in the Left-Lateral Tilt Position in a Pregnant Woman with Premature Placental Abruption Utilizing a Videolaryngoscope.

Case A 24-year-old pregnant woman was admitted to our hospital with decreased fetal heart rate. Obstetric examination revealed premature placental abruption; emergent caesarean section was planned under general anesthesia. On entering the operating room, the patient showed severe vital sign deterioration (blood pressure, 75/45 mm Hg; heart rate, 142 beats per minute). As left uterine displacement may worsen the premature placental abruption, the patient was placed in the left-lateral tilt position by rotating the operating table to release compression on the inferior vena cava by theuterus. To avoid circulatory collapse, rapid-sequence intubation was performed in this position. Tracheal intubation was performed with the Pentax-AWS Airwayscope (AWS videolaryngoscope, AWS; HOYA, Japan) to obtain a good laryngeal view and minimize stress from laryngoscopy. After sufficient oxygenation, 120 mg of thiopental was administered. A second anesthesiologist performed cricoid pressure and 50 mg of rocuronium was administered after confirming loss of consciousness. This was followed by insertion of the AWS with a thin intlock into the mouth. Tracheal intubation was performed uneventfully. Discussion Rapid-sequence intubation in the left-lateral tilted position with the AWS videolaryngoscope may be beneficial for pregnant women with vital sign deterioration.

Premature placental abruption is a serious condition in which the placenta partially or completely separates from the uterus before delivery. This condition can deprive the fetus of oxygen and nutrients, and cause severe bleeding leading to vital sign collapse, which can be dangerous to both the mother and fetus. In cases of premature placental abruption, termination of pregnancy by caesarean section is the standard procedure for rescuing both lives.1

Challenges encountered during emergent induction of general anesthesia in pregnant women include vomiting and difficult airways.2 Also challenging are cases of shock due to disseminated intravascular coagulation. Here, we report the successful rapid-sequence intubation of a pregnant woman using a videolaryngoscope in the left-lateral tilt position.

Case Report

A 24-year-old pregnant woman (height, 152 cm; weight, 55 kg) was admitted to our hospital with decreased fetal heart rate. Obstetric examination revealed premature placental abruption; emergent caesarean section was planned under general anesthesia.

On entering the operating room, the patient showed severe vital sign deterioration (blood pressure, 75/45 mm Hg; heart rate, 142 beats per minute). We considered the possibility that manual left uterine displacement may worsen premature placental abruption, leading to further vital sign deterioration. The patient was placed in the left-lateral tilt position by rotating the operating table to release compression on the inferior vena cava by the uterus.3 Medical staff stood on the left and helped prevent the patient from falling off the table. To avoid circulatory collapse, rapid-sequence intubation was performed in this position. Tracheal intubation was performed with the Pentax-AWS Airwayscope (AWS; HOYA, Japan) to obtain a good laryngeal view and minimize stress from laryngoscopy. After sufficient oxygenation, 120 mg of thiopental was administered. A second anesthesiologist performed cricoid pressure and 50 mg of rocuronium was administered after confirming loss of consciousness. This was followed by insertion of the AWS with a thin intlock into the mouth. Tracheal intubation with a tube (internal diameter, 7.0 mm) was performed uneventfully. After tracheal intubation, nitrous oxide and sevoflurane were administered. The infant was surgically delivered and vital signs recovered gradually with colloid infusion. Postoperative analgesia was performed with intravenous fentanyl and transversus abdominis plane block with ropivacaine. She was extubated in the operating room uneventfully. The Apgar score of the infant was 4 at 1 minute, and 9 at 5 minutes. The infant and mother were discharged with no major complications on postoperative day 7.

Discussion

Airway management with general anesthesia, even for elective caesarean section, is potentially difficult because patients have a low tolerance to hypoxia, high risk of aspiration from a rise in gastric pressure, and unique upper airway narrowing.2 4 The incidence of failed tracheal intubation is much higher in pregnant patients than in nonpregnant patients. In emergent situations, the difficulty increases. The American Heart Association 2010 cardiopulmonary resuscitation guidelines recommend early and careful securing of the airway during emergencies in pregnant women.5

The conventional Macintosh laryngoscope is the most widely used laryngoscope for tracheal intubation in obstetrics airway management, but its use requires skill and the incidence of inaccurate intubation can be unacceptably high, especially for occasional operators. Failure of tracheal intubation during cardiopulmonary resuscitation can result in serious complications such as stomach expansion, vomiting, and hypoxia, leading to poor outcomes.2 4

The AWS is a videolaryngoscope for tracheal intubation designed to provide a clear view of the glottis and its surrounding anatomy.6 7 The AWS improves the laryngeal view and its tube guide facilitates rapid and accurate tracheal intubation, even for difficult cases such as cervical neck immobility and morbid obesity.6 8 Increasing evidence indicates that the AWS is suitable for tracheal intubation during emergent situations, such as cardiopulmonary resuscitation or various position.9 10 11 Furthermore, the AWS requires less operator skill and is well suited for operators who perform infrequent tracheal intubations.12 Several simulation and clinical reports have attested to the utility of the AWS for rapid and definite tracheal intubation during obstetric emergencies.13 14 One simulation study showed the utility of AWS during continuous chest compression in the left-lateral tilt.13 Kariya et al demonstrated the utility of awake intubation during Cesarean section.14

There were three major advantages to using the AWS in this case. First, the AWS allowed for a good laryngeal view via the indirect glottis view function, although laryngoscopy was anticipated to be difficult due to late pregnancy.15 Second, rapid-sequence tracheal intubation was performed uneventfully in the left-lateral tilt position with the AWS, which has been successfully used in various positions.9 14 Third, stress from laryngoscopy was minimized by using the AWS, which allowed for the use of a relatively small amount of thiopental to avoid vital sign collapse.16

Our findings suggest that rapid-sequence intubation in the left-lateral tilted position with the AWS videolaryngoscope may be beneficial for emergent airway management of pregnant women.

Patient Consent

A written consent was obtained from the patient for publishing this report.