Acute Chest Syndrome During Pregnancy: Presentation and Outcome

There is very little data on acute chest syndrome (ACS) during pregnancy in patients with sickle cell disease (SCD). Having been following a treatment protocol that necessitates exchange transfusions during pregnancy in patients who have a severe course of sickle cell disease and history of previous maternal and/or fetal complications as well as prophylactic chest physiotherapy in patients who are at risk of ACS, we planned to study the rate and course of ACS during pregnancy at our institution.

As chest X-rays (CXR) are not commonly done during pregnancy, we defined ACS as an acute respiratory illness with lower respiratory tract symptoms and signs that are likely reflecting or are equivalent to a finding of a new pulmonary infiltrate. We reviewed the electronic records of women with SCD over the age of 18 years who were admitted to our hospital between the period of June 2006 and June 2010.

We identified a total of 60 patients who had one or more pregnancies during this period, 5 of whom met our definition of ACS. Median age was 26 years (range: 25–34). Two, 2 and 1 were in their first, second and fourth pregnancies, respectively. ACS occurred during different trimesters of pregnancy (first: 1, second: 2 and third: 2). ACS was the reason for admission in 2, while acute painful episodes and decreased fetal movement were the reason in 2 and 1, respectively (with ACS developing within a median of 1 day post-admission; range: 1–6, in the latter two groups). All patients presented with fever and shortness of breath, 4 had cough and 4 had decreased oxygen saturation < 95%. All had decreased breath sounds and dullness to percussion, 4 had coarse crackles and 3 also had wheezes. There was a tendency to involve the lower lobes (Right in 1 and bilateral in 4). Two patients had pleural effusions (one seen on ultrasound and one on CXR done immediately after delivery in a patient who had ACS late in the third trimester). Only one had a positive culture (E. coli on blood culture). All patients had an increase in lactate dehydrogenase, LDH, compared to their baseline (median increase from baseline: 173, range: 101–530) and C-reactive protein, CRP (median increase from baseline: 90; range: 23 – 170). All episodes of ACS resolved completely with a median duration of hospitalization of 13 days (range: 4 – 23) with a treatment protocol consisting of intravenous hydration, morphine for pain control, chest physiotherapy, broad-spectrum antibiotics, bronchodilators and red cell transfusions (simple in one and simple + exchange in 4). Only one patient required admission to the intensive care unit where she received non-invasive positive pressure ventilation. All pregnancies ended up in live births. However, 2 of these were preterm.

Our analysis indicates that the rate of ACS during pregnancy is low and its course is uncomplicated at our institution, which might reflect the pre-emptive strategy that we have been following. A prospective study with a control group to examine the exact incidence, risk factors, course and outcome of ACS during pregnancy is warranted.

Alkindi: Sultan Qaboos University: Employment, Research Funding.