Due to the oxygenation difficulties, the patient should remain intubated and be admitted to the ICU for mechanical ventilation. The airway must be secured by an endotracheal tube, perhaps with the help of a fiberoptic bronchoscope.

The ICU team needs to know that extubation must be carried out with a difficult intubation cart handy, and with an anesthesiologist standing by. Upon arrival in the ICU, further laboratory studies are required: CBC, blood gas analysis, and chest X-ray, and, finally, a specific treatment plan must be decided upon.

Assuming that the oxygen transport function of the erythrocytes is normal, the hypoxemia was most likely caused by ventilation–perfusion mismatch. The low S_pO₂ could have been caused by:

The high fine crackles were caused by alveolar fluid accumulation; aspiration causes course crackles. Many different diagnoses must be considered with this patient, such as infection or pulmonary edema. Considering the sudden and intense occurrence, pulmonary edema is the most likely diagnosis. The patient had been treated with tocolytics (β-mimetics) for many days. The ensuing increase of antidiuretic hormone (ADH) secretion leads to fluid retention which, together with the reduced colloid pressure of pregnancy, leads to pulmonary edema [2].

Another possibility is amniotic fluid embolism, which typically presents in two phases: first with initial pulmonary hypertension and right-sided heart failure, followed by a decrease in cardiac output and lung edema, hypoxia, and hypertension.

The answer to this question is not easy; one must probably first differentiate between an emergency procedure (as in this case) and elective procedures.

The concept of increased risk of aspiration in pregnant women was first described by Dr. Mendelson in 1946, and has since become well established in the heads and in the books of anesthesiologists worldwide. In the 1940s, women in labor were allowed to eat and drink freely. In the work of Dr. Mendelson, inexperienced young residents would carry out the anesthesia with ether masks [6] which are known to cause nausea and vomiting. The conclusions of these observations are well known – pregnant women have an increased risk of aspiration, being that intra-abdominal pressure is increased and the lower esophageal sphincter pressure is decreased.

More recently, some research has suggested that despite hormonal and abdominal pressure changes, gastric emptying is not delayed during pregnancy [7]. In addition, a large study of 1067 elective C-sections using laryngeal mask airways showed no increased aspiration risk [5]. Slowly, anesthesiologists are beginning to speak out against the theory of increased risk of aspiration in pregnant women, at least during elective C-sections [3]. In the presented case, however, the situation was different because pain, infection, and stress reduce gastric emptying, regardless of pregnancy.

The topic of delayed stomach emptying in pregnant women is an example of how difficult it is and how long it takes to change an established medical (and nonmedical) dogma. The influence of medical books is enormous, due to the fact that the authors do not take the time to critically examine dogmas.