Urgent C-section under GA in a pt with osteogenesis imperfec
Pregnancy in women who have OI is rare and carries a high risk for maternal morbidity. These pregnancies should be managed by a multidisciplinary team and patients need to be aware of the risks, so they can balance them against the benefit of having a child. The mode of delivery often depends on obstetric indications. However, because of the fragility of the maternal skeleton and cranio-pelvic mismatch, cesarean delivery is often preferred. The following case report has been published in Anesthesiology News.

A 26-year-old woman, gravida 3, para 2, was admitted from clinic at a gestation of 31 weeks and 5 days for a 1-week history of cough and worsening shortness of breath. She had a past medical history of de novo OI type III, severe scoliosis, gastroesophageal reflux disease, restrictive lung disease, and mild intermittent asthma, with a self-reported history of more than 300 fractures.

At a gestation of 32 weeks and 5 days, the patient began to experience increased blood pressure. She was diagnosed with gestational diabetes and pre-eclampsia that advanced to early hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome. The concern about early HELLP syndrome prompted the decision to proceed urgently with a cesarean delivery.

The patient had a Mallampati class I airway, limited cervical neck range of motion, and a thyromental distance of less than 2 cm. Preoperatively, she received 30 mL of sodium citrate. She was positioned supine on the operating table, with a roll under her right hip and careful placement of padding and blankets to minimize the risk for fracture.

Standard monitors were placed. To avoid excessive neck extension and rapid desaturation as a result of her limited functional residual capacity, the patient underwent an awake fiber-optic intubation. She was also given 3 L of oxygen by nasal cannula, 0.2 mg of glycopyrrolate, and 5% lidocaine jelly to topicalize her upper airway; in addition, her posterior oropharynx and vocal cords were sprayed with nebulized 2% lidocaine. A 5.0 cuffed endotracheal tube was able to be advanced into the trachea, with 20 mg of propofol supplemented during endotracheal intubation.

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