2025 FSA Podium and Poster Abstracts

Introduction: Subglottic stenosis (SGS) in pregnancy is a rare, but potentially life-threatening condition characterized by airway narrowing below the vocal cords. SGS can either be congenital or acquired, often due to prior intubation, tracheostomy, or conditions like Wegener’s granulomatosis, sarcoidosis, or GERD. In pregnancy, SGS symptoms – such as cough, shortness of breath, and progressive respiratory distress – can be easily mistaken for more common conditions such as asthma or recurrent bronchitis. Common treatment options for SGS include tracheoscopy, dilation, scar band lysis, and elective tracheostomy, with endoscopic balloon dilation being the most common intervention. However, the management of SGS during pregnancy presents complex challenges, due to the need to balance maternal and fetal safety. Currently, there are no universally accepted guidelines for SGS management during pregnancy, necessitating individualized treatment plans tailored to each case. This case highlights a successful approach to managing symptomatic SGS in the second trimester of pregnancy.

Methods/Case Report: A 26-year-old female, G4P2012 at 18.1 weeks by 9-week ultrasound, presented with acute asthma exacerbation and progressive shortness of breath. The patient reported shortness of breath starting a month ago after an admission for hyperemesis gravidarum complicated by a syncopal episode. Imaging at that time showed pneumomediastinum, leading to intubation for suspected esophageal perforation. After 2 days, she was extubated without surgical intervention following a gastrografin study that ruled out perforation. Her shortness of breath was more severe when lying down and her O2 saturation was 100% in room air and 92% with exertion. IV steroids for presumed asthma exacerbation showed no improvement. ENT consultation and fiberoptic exam revealed 85% subglottic stenosis, with the scope unable to advance past the vocal cords. 

The patient was transferred to the ICU and scheduled for balloon dilation with ENT. Obstetrics was consulted for multidisciplinary care given the patient’s 18-week pregnancy. Intraoperative fetal monitoring was not used, per ACOG guidelines recommending continuous fetal heart rate monitoring starting at 23-24 weeks gestation. However, fetal heart tones were obtained before and after the procedure. Teratogenic medications were avoided. The airway was topicalized with nebulized lidocaine and 1ml of racemic epinephrine before induction. Propofol was titrated by increments of 20mg to maintain spontaneous ventilation. Sevoflurane and ketamine were also titrated to maintain spontaneous ventilation. Jet ventilation was conducted using an 8 French cook catheter (at FiO2 100%, PSI 30) as the ENT surgeon performed rigid bronchoscopy to balloon dilate the airway.  After successful dilation, the surgeon intubated with a 6.0 ETT which was removed by the anesthesia provider once extubation criteria were met. Postoperatively, the patient reported symptom resolution at time of discharge. She did not require readmission and her delivery 5 months later was uneventful.

Conclusion: Limited literature exists on anesthetic management of SGS during the second trimester. Pregnancy may complicate diagnosis and lead to progression of symptoms, requiring prompt treatment for SGS. This particular case further illustrates the safe and effective treatment of SGS using balloon dilation during the second trimester.