Journal of Obstetric Anaesthesia and Critical Care

: 2020  |  Volume : 10  |  Issue : 2  |  Page : 98--105

Protocol-based management of acute pulmonary edema in pregnancy in a low-resource center

Kousalya Chakravarthy1, T Swetha2, Praveen K Nirmalan3, Anuradha Alagandala4, Nagamani Sodumu5,  
1 Department of Anesthesia, Modern Government Maternity Hospital (MGMH), Osmania Medical College, Hyderabad, Telangana, India
2 Department of Anesthesia Modern, Government Maternity Hospital (MGMH), Hyderabad, Telangana, India
3 Manasvin's Centre for Marital and Family Therapy, Hyderabad, Telangana, India
4 Department of Anesthesia, MGMH, Osmania Medical College, Hyderabad, Telangana, India
5 Department of Obstetrics and Gynaecology, MGMH Osmania Medical College, Hyderabad, Telangana, India

Correspondence Address:
Dr. Kousalya Chakravarthy
2-1-423, Esha Sadan, Street No. 4, Nallakunta, Hyderabad - 500 044, Telangana


Context: Acute pulmonary oedema (APO) in pregnant women is associated with increased maternal morbidity and mortality. Aim: The aim of this study was to evaluate the risk reduction strategy by a protocol-based approach to the management of APO in pregnancy in a low-resource center. Settings and Design: The study was conducted in a single obstetric tertiary care public sector hospital for 12 months. Materials and Methods: The pregnant women admitted with acute shortness of breath (SOB) were divided into two groups based on the implementation of pulmonary edema protocol. The data before protocol (Group A) and after (Group B) were compared. Results: A total of 38 patients were admitted with acute SOB. The incidence of APO was 0.10% (95% CI: 0.08,0.14). Majority (Group A: 92.87%; Group B: 81.25%) were admitted in the third trimester. Hypertension was the most common etiology (71.42% in Group A; 81.25% in Group B), followed by cardiovascular causes (42.85% in Group A; 6.25% in Group B) and sepsis (21.42% in Group A; 18.75% in Group B). Caesarean section was carried out in 57.14% in Group A; 62.5% in Group B. Noninvasive Ventilation (NIV) was started in 8 of 16 cases in Group B. Regional anesthesia was used in 87.5% in Group A and 100% in Group B. The maternal mortality was 9 (64.28%) in Group A as compared to 1 (6.25%) in Group B; P = 0.001. Conclusion: The protocol-based algorithm for APO in pregnancy decreases the maternal mortality. Hypertensive disorders of pregnancy are the most common cause followed by cardiac disease. NIV is useful in APO.

How to cite this article:
Chakravarthy K, Swetha T, Nirmalan PK, Alagandala A, Sodumu N. Protocol-based management of acute pulmonary edema in pregnancy in a low-resource center.J Obstet Anaesth Crit Care 2020;10:98-105

How to cite this URL:
Chakravarthy K, Swetha T, Nirmalan PK, Alagandala A, Sodumu N. Protocol-based management of acute pulmonary edema in pregnancy in a low-resource center. J Obstet Anaesth Crit Care [serial online] 2020 [cited 2020 Oct 26 ];10:98-105
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Full Text


Acute pulmonary oedema (APO) in pregnant women is a life-threatening condition with increased maternal morbidity and mortality.[1] The severity of APO is higher in pregnancy compared to nonpregnant women. Coexisting hypertensive disorders of pregnancy (HDP) and peripartum cardiomyopathy (PPCM) contribute to the higher morbidity and mortality. Pregnancy may unmask the preexisting heart disease where in the patient presents as APO first time in pregnancy.[2],[3] This study is to evaluate the factors contributing to pulmonary edema in pregnancy and to analyze whether a protocol-based management can decrease the maternal morbidity and mortality.

Aims and objectives

The aim of this study was to evaluate the risk reduction strategy by a protocol-based approach to the management of APO in pregnant patients in a low-resource hospital.

 Materials and Methods

The study was conducted in a single obstetric tertiary care public sector hospital. The efficacy of protocol-based management of APO in pregnant patients was evaluated over 12 months. The project was reviewed by Department of Anesthesia and Critical Care, and Department of Obstetrics and Gynaecology. Ethics committee approval was obtained. The study included all the pregnant patients admitted with pulmonary edema. The subjects were divided into two groups based on the implementation of pulmonary edema protocol (study protocol) in September 2018. The patients admitted between March 2018 and August 2018 (6 months pre study-protocol) were taken as Group A or the control group. Details of study subjects for Group A were retrieved from the hospital records. The patients admitted with APO from September 2018 to March 2019 (6 months post study protocol) were taken as Group B. Study subjects for Group B were recruited from the patients admitted in the hospital during the study period. The inclusion criteria of the study were pregnant women of all age groups and gestation up to 6 weeks of postpartum period, admitted in the hospital with a diagnosis of pulmonary edema. Patients who were not pregnant/or those after 6 weeks postpartum and those with a prepregnancy diagnosis of interstitial lung disease, pulmonary fibrosis, and chronic lung diseases such as tuberculosis and sarcoidosis were excluded from the study.

The primary outcome or the end point of the risk reduction strategy was prevention of maternal mortality with the implementation of protocol-based management of APO in pregnancy. The secondary outcome variables were in-house vs. outside referrals, etiology/cause of the APO, pregnancy associated risk factors such as advanced maternal age, obesity, preeclampsia, multiple gestation, premature rupture of membranes (PROM) with sepsis, and drug-induced pulmonary edema. Preexisting cardiac conditions such as chronic hypertension, ischemic heart disease, rhythm disturbances, congenital heart diseases, acquired valvular lesions, arrhythmias, cardiomyopathy, and iatrogenic intravenous fluid overload if any were noted. Other rare causes of pulmonary edema such as embolic disorders (amniotic fluid embolism [AFE], pulmonary embolism), or pheochromocytoma was noted. The mode of delivery, echocardiographic findings, mode of ventilator support, need for transfer to cardiac center, total intensive care unit (ICU) stay/total hospital stay, and fetal/neonatal outcome were analyzed.

The patients admitted with shortness of breath (SOB) with clinical features consistent with pulmonary edema were monitored with pulse oximetry, respiratory rate counted clinically, and blood pressure monitored with noninvasive blood pressure (NIBP) monitor. The diagnosis of APO was made by the presence of SOB, increased respiratory rate more than 35 per minute, fall in saturations to less than 94% on room air and confirmed by bilateral crepitations on auscultation of the lungs. Once the clinical diagnosis was made, the management was established according to the hospital protocol of APO [Figure 1]. The patients were assessed for clinical improvement every 15 min. The increase in the saturations was taken as a positive outcome. Clinical stabilization was defined as improvement of saturations to more than 94% and decrease in the respiratory rate to less than 35 per minute. The treatment given and the time of initial stabilization of the patient were noted. Mode of delivery, type of anesthesia and any morbidity or mortality, and neonatal outcome were noted. All the patients were followed till discharge. The data were compared to the data extracted from the hospital records over an equivalent 6 months period before the institution of protocol for the management of APO. The statistical analysis was performed to explore pre- and post-protocol differences. Point estimates, 95% confidence intervals around point estimates, were determined. P Value was obtained by Student's t test for continuous variables and Fisher's exact test for categorical variables. A value of P < 0.05 was taken as statistically significant.{Figure 1}


A total of 38 patients admitted with acute SOB, during the study period of 12 months were analyzed. Patients admitted in period of 6 months before the implementation of pulmonary edema protocol (March 2018–August 2018) were referred to as Group A. The pregnant patients who were admitted with pulmonary edema during the study period of 6 months after the instituting the protocol (September 2018–February 2019) were referred to as Group B.

The details of subjects in Group A were retrieved from the hospital records. There were 16 pregnant patients admitted with SOB in the 6 months prior to the implementation of the protocol for pulmonary edema. Two of them were excluded from the study, one with a PPCM with SOB, but without pulmonary edema and the other patient who was referred in acute SOB with a diagnosis of pulmonary embolism. In the study period of 6 months after the implementation of protocol (September 2018–February 2019), a total of 22 pregnant women were admitted with acute SOB. Three of them were excluded (one nonpregnant lady, one case of pulmonary tuberculosis and one case of lower respiratory tract infection). Of the 19 cases in Group B, protocol was not followed in 3 cases. The data retrieved in Group A (n = 14) were compared to the data recoded in Group B (n = 16) [Figure 2].{Figure 2}

The demographic data were comparable in both the groups [Table 1]. Majority of the patients were unbooked cases referred from the peripheral hospitals for tertiary care (87.5% in Group B). Many of the patients were admitted in third trimester of pregnancy. The mean gestational age and preterm deliveries were comparable in both the groups. The most common cause of pulmonary edema was HDP (71.42% in Group A vs. 81.25% in Group B). Cardiac lesions were the next common cause of pulmonary edema in the study [Table 2]. A total of five cases of PPCM, and three valvular heart diseases presented with APO. There were no cases of ischemic heart disease or pulmonary edema due to rhythm disturbances. Sepsis (3 [21.42%] in Group A vs. 3, [18.75%] in Group B) and severe anemia were other causes contributing to pulmonary edema. The other risk factors evaluated were the secondary causes of hypertension, hyperthyroidism, pulmonary embolism, iatrogenic fluid overload, and pregnancy-related factors such as multiple gestation, AFE, and tocolytic induced pulmonary edema. The risk factors were comparable in both the groups (P > 0.05) [Table 2].{Table 1}{Table 2}

The mode of delivery was by caesarean section in 8 of 14 cases in Group A and 10 of 16 cases in Group B [Table 3]. Regional anesthesia was given in seven cases in Group A (five epidurals and two subarachnoid blocks) and one patient received general anesthesia. Perimortem caesarean delivery was carried out in one patient but could not be revived. In Group B, all 10 cases received regional anesthesia (eight SAB, one incremental epidural, and one combined spinal epidural [CSE]).{Table 3}

The gestational age at the time of delivery was comparable in both the groups [Table 4]. The incidence of antenatal and postnatal pulmonary edema and the need for the ventilatory support did not differ significantly between the two groups. The risk reduction strategies of medical management and noninvasive ventilation (NIV) were implemented in Group B. In Group B, 8 of 16 patients (50%) received NIV support, as continuous positive airway pressure (CPAP). Two patients required mechanical ventilation, of which one was shifted to multispeciality center for further care and management. The decreased maternal mortality was reflected in the increased ICU and hospital stay in Group B as compared to Group A, which was statistically significant with a P < 0.001 and 0.03, respectively.{Table 4}

There were nine maternal deaths in Group A. Three of them succumbed in the antenatal period before delivery. Perimortem caesarean delivery (PMCD) was carried out in one patient but both lives could not be saved. Five maternal deaths occurred in the early postpartum period [Figure 2]. The application of protocol to the pregnant patients in Group B significantly decreased the maternal mortality to 1 (6.25%) as compared to 9 (64.28%) in Group A; P = 0.001. The reduction in the neonatal mortality was not statistically significant.


APO in pregnancy is a rare but life-threatening condition with high maternal and perinatal morbidity and mortality.[4],[5] The incidence varies from 0.08% to 0.5%[6] or may reach as high as 2.9% to 3.0%.[7],[8],[9] The diagnosis of pulmonary edema is essentially clinical. Patients present with SOB, dyspnea, tachypnea, tachycardia, hypoxemia, and diffuse crepitations in the lungs. The causes of APO in pregnancy include preeclampsia, cardiogenic/tocolytic induced, fluid overload, multiple gestation, and infection.[10]

Basis for the formulating the algorithm

This study was conducted in a tertiary public sector maternity hospital with a high referral rate, low staff patient ratio, and lack of resources for immediate multispeciality care. A hospital-based protocol was developed with a hypothesis that an algorithmic approach can standardize the care in this dire emergency.

 Components of the Algorithm for Apo in Pregnancy [Figure 1]

Initial stabilization

The algorithm begins with the standard emergency approach to airway, breathing, and circulation.[11] The immediate management of APO includes oxygenation, ventilation, and control of circulation. Further evaluation of the etiological causes and management was based on the hemodynamic status of the patient at the time of presentation (hypertension, normal blood pressure, or hypotension). Dennis et al.[12] have advocated similar approach to APO in pregnancy by segregating the condition depending on the presence of hypertension.

APO with hypertension or normotension

Hypertensive disorders are the most common cause of APO in pregnancy.[9],[10],[12],[13] The patients with severe preeclampsia and eclampsia and those with PPCM can present with hypertension and pulmonary edema.[14] The etiological factors for APO with hypertension are incorporated in the algorithm. The standard care of head-end elevation and oxygen supplementation were proposed for this group of patients, along with venodilator Nitroglycerine (glyceryltrinitrate) initiated at a rate of 0.5 mcg/kg/min and titrated accordingly. ESC/European Society of Hypertension guidelines, 2011, advocate glyceryl trinitrate as the venodilator of choice in severe preeclampsia.[15] Intravenous furosemide was proposed for venodilation and diuresis.[16] The algorithm alerts caution on the use of bolus intravenous fluids, intravenous labetalol, and magnesium sulfate in APO. Intravenous boluses of labetalol can aggravate the condition owing to its negative chronotropic and negative inotropic effects particularly when used along with loading dose of magnesium sulfate.[12],[17] Magnesium sulfate can precipitate APO in pregnant or postpartum women.[18],[19],[20]

NIV either in the form of CPAP or BiPAP has a positive role in cardiogenic pulmonary edema and was incorporated in the algorithm. Several recent studies agreed upon the judicious use of NIV in pregnancy.[21],[22] NIV provides high inspired oxygen concentration, displaces fluid from the alveoli into the pulmonary circulation, decreases the work of breathing, and decreases the need/risks for tracheal intubation.[23] Intravenous morphine 2–3 mg acts as a venodilator and anxiolytic and can be used cautiously.[24]

APO with hypotension

Sepsis, systolic dysfunction of the heart, and occasionally the embolic phenomenon such as AFE can present as APO with a low blood pressure.[25],[26],[27] Noradrenaline has been the vasopressor and inotropic of choice in septic shock and anaphylactoid reactions such as AFE.[28] In hypotension with pulmonary edema, the algorithm suggests noradrenaline, early echo, and early intubation.

Peripartum management

After the stabilization of mother, the algorithm incorporates the protocol to manage the delivery and immediate postpartum period.

The overall incidence of APO in this study was 0.10% (95% CI: 0.08,0.14), which was comparable to the incidence in other studies.[5],[6],[7],[8] The two groups, A and B, before and after the institution of algorithmic approach were comparable in the demographic data. The mean age of patients was 25.87 ± 2.64 years in Group A and 24.06 ± 1.98 years in Group B, which was similar to the study of Sciscione et al. with a mean age of 27.6+/- 6.4 years and Dolley et al. with a mean age of 28.6 years, respectively.[5],[29] Majority of the patients (92.87% in Group A and 81.25% in Group B) were admitted in the third trimester of pregnancy. The mean gestational age at the time of admission was 35.93 weeks in Group A vs. 35.73 weeks in Group B; P = 0.93. Dolley et al. documented similar results with mean gestational age of appearance of pulmonary edema at 31.2 ± 3.1 weeks.[29]

APO was found in 58.0% of cases before delivery in the study by Pordeus et al.[30] Similar results were found in the cohort study by Sciscione et al.[5] The overall increase in the blood volume and a decrease in the plasma colloid oncotic pressure combined with the decreased intravascular volume in the preeclampsia and eclampsia predisposes the pregnant women to develop APO especially after 32 weeks of gestation.[31] The incidence APO before delivery was higher in this study. It may be because of the added effect of inadequate optimization of HDP and the prevalence of nutritional anemia in the lower socioeconomic group of the study population.

HDP were the most common etiological factor contributing to APO (71.42% in Group A; 81.25% in Group B). Pordeus et al. found similar results, where hypertension was the etiologic cause in 62% of cases.[31] Hypertension was the most common cause of pulmonary edema in the pulmonary edema preeclampsia evaluation (PEPE) study by Gandhi et al. The authors found highest risk in early onset preeclampsia.[32] The second most common etiology in this study was cardiovascular conditions with valvular heart diseases and cardiomyopathy contributing to 42.85% of cases in Group A and 12.5% in Group B. Pordeus et al. observed an incidence of 16% of cardiovascular etiology.[31] In PEPE study by Gandhi et al., multiparity was associated with a lower risk of pulmonary edema but it was not observed in this study.[32]

The other risk factors found in the study were sepsis and severe anemia. Sepsis was found in 21.42% in Group A and 18.75% in Group B. Sepsis can cause both systolic and diastolic dysfunction, decreased diastolic filling, and predisposing the patients to increased risk of pulmonary edema.[33],[34] Caesarean section was the primary mode of delivery in patients admitted with APO (57.14% in Group A and 62.5% in Group B). In the study by Pordeus et al. 78.0% of deliveries were by Caesarean section.[31] Regional anesthesia was used in 87.5% of cases in Group A and 100% of cases in Group B. There were altogether 4 cases of postpartum pulmonary edema in the study. Fluid overload was the cause of pulmonary edema in 18.75% of cases in Group B. Similar results were seen in the study by Sciscione et al.[5] (11 patients, 21.5%) and a higher incidence by Pordeus et al.[31] (34.0%).

This study agrees with the observation of Pordeus et al. that compliance with recovery care protocols, accelerates clinical improvement, and reduces hospitalization time.[31] The execution of risk reduction strategies increased survival in Group B, which was paradoxically reflected as increased duration of stay in the ICU (2.07 vs. 5.13; P < 0.001) and the total duration hospital stay (6.15 vs. 10.6; P = 0.03). The risk reduction strategies used in this study were supplemental oxygen, avoidance of intravenous bolus labetalol, and magnesium sulfate, fluid restriction, loop diuretics, nitroglycerine as applicable, and NIV early than late. NIV was started in 8 of 16 cases of pulmonary edema in Group B. The study documents 64.28% maternal mortality in the early postpartum period in Group A. The placental auto transfusion, oxytocic drugs, amount of blood loss, surgical stress, and perioperative fluid management, may all contribute to the deterioration of the patient in the early postpartum period. There was no maternal mortality in the immediate postpartum in Group B. Implementation of protocol-based risk reduction strategies reduced the peripartum and perioperative complications.

The statistically significant decrease in the maternal mortality (nine in Group A [64.28%] vs. one in Group B [6.25%]; P = 0.001) emphasizes the efficiency of a protocol-based algorithmic approach to APO in pregnancy. However, the neonatal outcome was not improved significantly. This may be because of the late referrals causing irreversible fetal hypoxia.

Limitations and strengths of the study

As APO in pregnancy is a relatively rare event, the sample size was limited. Single-center study also contributed to the limitation of the sample size. Nonavailability of echocardiography, point of care ultrasound, arterial blood gases (POC ABG), 24-h X-ray facilities, and lack of resources for multispecialty approach are the other limitations. Nevertheless, the fact that APO is essentially a clinical diagnosis and performing echocardiography after stabilization that enabled the confirmation of the etiology were the strong points of the study.


APO in pregnancy is a medical emergency with high maternal and perinatal morbidity and mortality. HDP are the most common cause of APO in pregnancy followed by cardiac disease. The protocol-based algorithmic approach to APO in pregnancy facilitates early identification of probable cause, early application of risk reduction strategies, helps in maintaining the uniformity in the management, decreases the maternal morbidity and mortality, and aids a better maternal outcome. Maternal stabilization should be the priority over the delivery of fetus. NIV can be used in APO in pregnancy. Regional anesthesia can be used after the initial maternal stabilization.


We thank our Anesthesia colleagues and our colleagues in the Department of Obstetrics and Gynaecology for extending their support in the implementation of the protocol.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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