BJOG: an International Journal of Obstetrics and Gynaecology

February 2002, Vol. 109, pp. 221 222

CASE REPORT

Acute tracheitis with severe upper airway obstruction

complicating pregnancy
S.L. Sholapurkar a,*, R.W.T. Slack b, A.F. Avery c, H.M. Tonge a, G.D. Dunster a
Case report
A 30 year old woman at 40 weeks of gestation with
three previous normal deliveries was admitted to the
delivery suite with a sudden onset of difficulty in breathing
for about two hours. She also complained of pain around
her neck and upper chest, and had dysphonia with marked
hoarseness. She had a history of some malaise and a mild
sore throat for the previous 48 hours. There was no history
of asthma, drug intake, allergy, calf pain or swelling, and
she was a non-smoker. Her antenatal course until that time
had been uneventful.
On examination she was very distressed and severely
dyspnoeic. Her temperature was 38C, pulse rate 100 beats
per minute, systolic/diastolic blood pressure 100/60mmHg
and respiratory rate 25/minute. Her face looked flushed
and an inspiratory stridor was noted. Examination of her
chest was normal. She was given 40% oxygen by mask
and her oxygen saturation was 98%. A cardiotocograph
showed a normal fetal heart rate. An ear, nose and throat
specialist was consulted. In view of the urgency of the
situation she immediately underwent direct flexible laryngoscopy in the outpatient clinic of the ear, nose and
throat department. The laryngoscopy showed a normal
glottis and supraglottis but marked inflammation of the
tracheal mucosa with a lot of exudates and crusting. A
diagnosis of acute severe tracheitis with upper airway
obstruction was made. In view of the crusting, it was felt
that there was a risk of complete obstruction of the
trachea. After consultation between obstetricians, anaesthetists and ear, nose and throat surgeons, a tracheostomy
under local anaesthesia was performed. Once the tracheostomy tube was safely inserted general anaesthesia was

Department of Obstetrics and Gynaecology, Royal United

Hospital, Bath, UK
b
Department of ENT, Royal United Hospital, Bath, UK
c
Department of Anaesthesia, Royal United Hospital, Bath,
UK
* Correspondence: Dr S. L. Sholapurkar, Royal United Hospital, Bath
BA1 3NG, UK.
D RCOG 2002 BJOG: an International Journal of Obstetrics and Gynaecology
PII: S 1 4 7 0 - 0 3 2 8 ( 0 2 ) 0 0 0 4 8 - 4

induced and a lower segment caesarean section performed.

There was no time to perform a lateral X-ray of the neck
before performing the tracheostomy.
A male infant was born in good condition and weighed
4.19kg. The interval between induction of anaesthesia and
delivery was 10 minutes. Umbilical cord arterial blood
analysis showed a pH of 7.32, pCO2 2.15kPa, pO2
7.48kPa and base excess of 15.9mmol/L. The high base
deficit and low pCO2 indicates that the infant had a
metabolic acidosis, probably resulting from the maternal
acidosis. The woman was prescribed co-amoxyclav 1.2g
intravenously eight-hourly and transferred to the ear, nose
and throat ward for close observation. Humidified oxygen
was administered by a face mask. A post-operative chest
X-ray was normal. Tracheal swabs did not show any
significant bacterial growth. She was given intensive
physiotherapy. Her condition improved rapidly over the
next two days without any need for assisted ventilation
and the tracheostomy tube was removed four days after
her operation. There was no other immediate post-operative complication apart from mild pyrexia. She was
discharged on the sixth post-operative day.

Discussion
Upper airway obstruction as a result of upper respiratory
tract infection is extremely rare in adults. It is classically a
disease of the paediatric population mainly because the
small diameter of the upper respiratory tract makes children
particularly vulnerable to total or subtotal obstruction.
However, recently adult infective upper airway obstruction
is being reported with increasing frequency, either because
of an increased incidence or heightened awareness 1. There
seems to be some overlap in classification of this condition
but three types of disease, acute epiglottitis, laryngotracheobronchitis or croup, and tracheitis have been reported.
There are several changes in the larynx in normal
pregnancy as congestion, oedema and occasional drying
and crusting of the laryngeal mucosa. About 60% 75% of
pregnant women report some hoarseness or breathlessness
which is rarely clinically significant 2. Infective upper airway
obstruction in pregnancy is extremely rare. Most obstetriwww.bjog-elsevier.com

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CASE REPORT

cians are unlikely to have seen or be aware of this serious

medical condition, but they may be the first clinicians to see
such a patient. There are only three cases of epiglottitis3 and
two of laryngotracheobronchitis in pregnancy2 reported in
the literature. To our knowledge acute tracheitis in pregnancy has not been reported previously.
Obstruction of the upper airway is very rare in pregnancy and can be life threatening. Acute upper airway
obstruction from infective causes is very rare in adults and
is characterised by dyspnoea, a barking cough, hoarseness,
fever and a varying degree of stridor. Indirect laryngoscopy will show swelling and inflammation of the larynx
when epiglottitis or laryngotracheobronchitis is present,
but will be normal in acute tracheitis. Endoscopic assessment is required to diagnose tracheitis which will show
purulent debris, mucosal ulceration and ooedema of the
subglottic larynx and trachea. Lateral X-ray of the neck
may or may not be abnormal. Acute tracheitis is most
often viral but sometimes there will be superinfection with
bacteria, such as haemolytic streptococci, H. influenzae or
S. aureus. During pregnancy cellular and humoral immunity is suppressed and may account for increased severity
of infection.
The differential diagnosis of infective upper airway
obstruction in pregnancy should also include laryngeal
oedema secondary to severe pre-eclampsia, iatrogenic
fluid overload, hereditary angiooedema, acute severe
asthma and rarely, enlargement of the thyroid. Treatment
must be swift and includes intravenous antibiotics, intravenous steroids, humidification and continuous monitoring
of the airway. If obstruction of the airway occurs, intubation or tracheostomy is necessary. If the fetus is premature, prolongation of pregnancy is possible provided
the response to treatment is satisfactory 2. Death from
adult respiratory distress syndrome and multi-organ failure

following acute upper airway obstruction has been

reported 4. The woman whose condition is reported here
had rapidly worsening dyspnoea and severe upper respiratory obstruction with a term pregnancy. Tracheostomy
under local anaesthesia was thought to be the safest
course of action, rather than induction of general anaesthesia and intubation, since it was feared that the process
of induction of anaesthesia may have resulted in temporary but possibly fatal complete obstruction to the airway.
Once the tracheostomy tube was inserted and the tracheal
toilet performed, the obstruction was relieved. Immediate
delivery by caesarean section was thought to be the safest
course of action since she was at term.

Conclusion
Acute infective upper airway obstruction in pregnancy is
very rare, but is a life-threatening condition of which
obstetricians should be aware.

References
1. Mayo Smith MF, Hirsch PJ, Woodzinski SF, et al. Acute epiglottitis in
adults: an eight year experience in the state of Rhode Island. N Engl J
Med 1986;314:1133 1139.
2. Ossoff RH, Wolf AD, Ballenger JS. Acute epiglottitis in adults: experience of 15 cases. Laryngoscope 1980;90:1155.
3. Glock JL, Morales WJ. Acute epiglottitis during pregnancy. South Med
J 1993;86:836 839.
4. Adolf MD, Oliver AM, Dejak T. Death from adult respiratory distress
syndrome and multiorgan failure following acute upper airway obstruction. Ear Nose Throat J 1994;73:324 327.
Accepted 14 August 2001

D RCOG 2002 Br J Obstet Gynaecol 109, pp. 221 222