2026 SOAP Annual Meeting

High risk delivery in a patient with significant hemoptysis: a neuraxial strategy supported by inhaled tranexamic acid.

Kenneth Nguyen, DO; Jessica Ansari, MD; Phillip Callihan, MD, PhD

Department of Anesthesiology, Perioperative, and Pain Medicine · Stanford Health Care

Background

•Hemoptysis is rare in pregnancy and presents unique anesthetic challenges

•Tranexamic acid (TXA) has been used as a noninvasive method to manage hemoptysis

•Treated with inhaled TXA with resolution of gross hemoptysis. However, cough remained productive of clotted blood with intermittent desaturation events when supine

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•CT angiography was negative for pulmonary embolism but showed right sided pulmonary debris

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•Flexible laryngoscopy showed prominent subglottic and interarytenoid vessels

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•Interventional pulmonology recommended bronchoscopy during cesarean delivery under GA

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•Primary concern: airway instrumentation and intubation with large ETT > catastrophic airway hemorrhage

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•Plan - cesarean delivery under neuraxial anesthesia with interventional pulmonology available for emergent bronchoscopy

-Oxymetazoline and dexmedetomidine pretreatment

-Oxygenation optimized using humidified high flow nasal cannula

•Successful reduced dose CSE with 9mg intrathecal (IT) bupivacaine, 15mcg IT fentanyl, + 100mcg IT morphine

-No episodes of hemoptysis during cesarean delivery

-Bronchoscopy on PPD3 revealed RLL vascular malformation

Discussion

-Consider nebulized TXA for hemoptysis in pregnancy

-Avoid emergent airway instrumentation in pregnant patients with airway vascular malformations

-Manage risk with appropriate timing for timing of bronchoscopy

2026 SOAP Annual Meeting

High risk delivery in a patient with significant hemoptysis: a neuraxial strategy supported by inhaled tranexamic acid

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