How to manage scrub typhus infection with ARDS in pregnancy?

Question

Hello doctor,

I need urgent advice regarding a 32-year-old female, 34 weeks pregnant, diagnosed with severe scrub typhus infection. She has developed acute respiratory distress syndrome (ARDS), requiring six liters of oxygen, with multiple eschars noted. Since Doxycycline is contraindicated, she was started on Azithromycin.

However, she is now showing signs of fetal distress with recurrent late decelerations. Her platelets have dropped to 45K, liver enzymes are rising, and she continues to have a persistent fever despite 72 hours of antibiotics. She is experiencing frequent contractions, and a recent echocardiogram indicates myocarditis with an EF of 40 percent. She is also showing signs of disseminated intravascular coagulation (DIC), with ongoing epistaxis and rising lactate levels. An emergency C-section is being considered, but there is concern about the bleeding risk. What would be the best immediate management plan in this situation?

Kindly advise!

Answer 1

Hello,

Welcome to iCliniq.

I understand your concern.

This is a critical case of scrub typhus with ARDS (acute respiratory distress syndrome), myocarditis, DIC, and fetal distress at 34 weeks of gestation, requiring urgent intervention. Here’s the recommended approach:

Emergency C-section is likely needed due to fetal distress and maternal instability. High bleeding risk due to DIC and thrombocytopenia (45K platelets); platelet transfusion may be required before surgery. The NICU team should be on standby for potential preterm complications. Continue Azithromycin (safe in pregnancy); consider Chloramphenicol if there is no improvement. Broad-spectrum antibiotics may be necessary if secondary infection or sepsis is suspected. Monitor for MODS (multi-organ dysfunction syndrome)—rising lactate and worsening liver function indicate systemic involvement. Optimize oxygenation for ARDS, and consider escalation if needed. Myocarditis (EF 40 percent): careful fluid balance, vasopressors if required, and inotropic support in consultation with cardiology. Manage DIC with FFP, cryoprecipitate, and platelet transfusion based on lab trends. Monitor closely for postpartum hemorrhage.

Given the high-risk nature of this case, immediate multidisciplinary management is essential, involving obstetrics, maternal-fetal medicine, infectious disease, cardiology, ICU, hematology, and neonatology.

I hope you are satisfied with my answer. For further queries, you can consult me at iCliniq.

Thank you.