A Mom’s Lifelong Breathing Issues Threaten Her Pregnancy – and Her Life
For immediate release: July 24, 2015
Multidisciplinary Team of UMMC Caregivers Collaborate, Innovate to Save Woman and Her Unborn Baby
Tinan Doualou Kouame never expected to spend the final weeks of her second pregnancy in the Medical Intensive Care Unit (MICU) at the University of Maryland Medical Center (UMMC). Mrs. Doualou had always had difficulty catching her breath, but what she thought was asthma turned out to be an underlying lung disease that caused pulmonary hypertension — a serious condition with often-deadly consequences for pregnant women. A few weeks into her third trimester, Mrs. Doualou landed in the MICU where a massive team of doctors, nurses and social workers from almost every corner of the hospital would work together to save her life and welcome her daughter to the world.
Transatlantic flights are the norm for Tinan Doualou Kouame, a 36-year-old mother who splits her time between Maryland and Africa’s Ivory Coast, where her husband and eight-year-old son reside. But on a flight home to Maryland during her second pregnancy, Mrs. Doualou became so short of breath she needed the flight crew to provide her oxygen. She was scared. Her life-long battle with what she thought was asthma had never been this bad before.
At 29 weeks pregnant, Mrs. Doualou was admitted to UMMC’s MICU – where some of the hospital’s most acutely ill patients receive 24/7 advanced cardio-pulmonary monitoring. Jeffrey Hasday, MD, Head of the Pulmonary and Critical Care Medicine Division at UMMC and Professor of Medicine at the University of Maryland School of Medicine, says, “In the MICU, we take care of cardiac patients, cancer patients, surgery patients – all comers. We’re like their primary care providers except most of the problems we take care of are very acute and potentially life threatening.”
The complexity of Mrs. Doualou’s illness required the kind of multidisciplinary care that UMMC is uniquely qualified to provide. Her underlying lung disease was managed by the Pulmonary and Critical Care teams in the MICU, but the pulmonary hypertension her lung disease had caused required expertise of Cardiology. And at 29 weeks pregnant, she needed the care of the Maternal and Fetal Medicine Division. Working side by side, these teams toiled around the clock to implement a specialized care plan for Mrs. Doualou and her unborn child.
The scarring from the lung disease and the pulmonary hypertension had caused the right side of Mrs. Doualou’s heart to fail. She couldn’t get enough blood flow through her lungs to provide sufficient oxygen for her body and her baby. Every breath was a struggle. “Blood volume and oxygen requirements change a lot during pregnancy and even more so during labor. Women with pulmonary hypertension are often counseled not to become pregnant because the risk of death is so high,” adds Dr. Hasday. For Mrs. Doualou, her pregnancy was becoming more dangerous every day and the only way to save her was to deliver her baby early.
Ozhan Turan, MD, Director of Fetal Therapy and Complex Obstetric Surgery at UMMC and Associate Professor of Obstetrics, Gynecology and Reproductive Sciences at the University of Maryland School of Medicine, had two patients to consider: Mrs. Doualou and her unborn baby. Delivering early would be Mrs. Doualou’s best hope for recovery, but delivering too early could cause serious complications for her baby. After many discussions, her care team decided to wait until week 32 to deliver – a point at which there are risks to consider such as infection, respiratory distress, bowel complications or even a brain bleed. However, delivery in the setting of pulmonary hypertension has a mortality rate for the mother as high as 50 percent.
Mrs. Doualou’s doctors had some difficult choices to make. Should she be allowed to labor or should she have a C-section? If she has a C-section, can she be intubated? Each of these scenarios carries significant risk and the pros and cons of each needed to be weighed carefully. “Her care really did take a village and was a completely collaborative approach,” says cardiologist Stacy Fisher, MD, director of Women’s and Complex Heart Diseases at UMMC and Assistant Professor of Medicine at the University of Maryland School of Medicine. “It was wonderful to work with such a phenomenal group, everybody receptive to everybody else’s thoughts and ideas and concerns.”
Ultimately, it was decided that Mrs. Doualou would be allowed to labor. The risks of surgery and intubation were too great.
Because Mrs. Doualou needed monitoring and care unique to the MICU, her care team transformed her room into a labor and delivery suite. MICU staff cleared the room next door so Neonatology could create a neonatal ICU bed in the MICU. OB anesthesiologists brought their equipment to Mrs. Doualou’s room, delivered the epidural and stayed on hand in case an emergency C-section would be needed. Nurses from Labor and Delivery were assigned to the MICU to support Mrs. Doualou’s obstetric needs. And the Pulmonary and Critical Care team from the MICU were on hand to monitor and support Mrs. Doualou’s lung function throughout the delivery.
Tracie Brown, BSN, RN, was especially connected to Mrs. Doualou’s care given that she had worked as a nurse in the MICU for three years before transferring to Labor and Delivery. “It was like my nursing career had led to this moment. I felt honored to care for her. Her strength throughout the experience gave me strength. And the open communication among disciplines really captured the integrity of the patient.”
One integral member of Mrs. Doualou’s care team deserves special thanks, Mrs. Doualou says. Social worker Catherine Miller managed to get Mrs. Doualou’s husband a visa in just one day so he could be with her for the birth of their daughter.
At 11:00 p.m. on March 11, approximately 23 hours after Mrs. Doualou was first induced, Lauren Kouame was born. She was 3.4 pounds. Thankfully, Lauren had no complications and was able to leave the Neonatal Intensive Care Unit (NICU) after just 4 weeks.
“This was truly one of the grandest efforts I’ve ever been a part of in my career from a multidisciplinary standpoint,” says Garrett Fitzgerald, MD, Maternal and Fetal Medicine fellow. “This experience further solidified that I’m privileged to train here with people who have unbelievable expertise and unbelievable willingness to go above and beyond to put this small family together.”
For Mrs. Doualou, the first 72 hours after the delivery were the most crucial for her survival. She needed to be monitored constantly as her body adjusted to no longer carrying a fetus. While she survived the acute illness that threatened her life and pregnancy, the challenges of her chronic condition remain; she has a difficult journey ahead of her now that she has been discharged from the hospital. She must carry oxygen with her at all times, and it’s possible she may need a lung transplant – but she is happy to be alive. “I’m really sick. I still have a long road to go but at least I’m alive. My baby is in good health. So that’s good for the moment,” Mrs. Doualou says. “The way I see it,” she adds, “is in Ivory Coast, I would have died because we don’t have that level of care over there. And I’m lucky to be here and to have my daughter and to have access to that care. I’m really sick but I’m really happy to be in this position.”