World-first: Experts at UHN, Sinai Health and SickKids develop plan to save critically ill mother and her baby
Medical experts from University Health Network (UHN), Sinai Health’s Mount Sinai Hospital and The Hospital for Sick Children (SickKids) collaborated to support a pregnant patient with pulmonary hypertension, through both a successful delivery and a double-lung transplant – saving the mother and her baby.
Physicians recommend that patients with pulmonary hypertension avoid pregnancy, given the high risk of death for the mother and baby. However, Candice Cruise was unaware of her condition until she reached 21 weeks of pregnancy. The usual medical option at this time would have been to terminate the pregnancy as the only way to save the mother in this extremely high-risk situation.
With coordinated expertise of multiple specialists – including thoracic surgeons, respirologists, intensive care physicians, obstetricians, anaesthesiologists, cardiologists, and neonatologists and acute care transport specialists – the team at Toronto General Hospital (TGH), UHN, was able to devise a novel plan, using an artificial lung device called the Novalung. It created an adaptable heart-lung blood flow state to stabilize Candice until she reached 29 weeks of pregnancy, to ultimately deliver her baby, and then carry Candice safely to an urgent double-lung transplant.
Saving both the mother and the baby in this fashion, and then bridging the mother to a successful lung transplant is another world-first achievement of the Toronto Lung Transplant Program, at UHN.
A rare life-threatening disorder, pulmonary hypertension is a condition that leads to extremely elevated blood pressure of the arteries in the lungs. This increased pressure makes it difficult for the heart to pump blood through the lungs, which eventually causes the heart muscle to fail. The condition is especially dangerous during pregnancy, since the growing baby naturally puts significant stress on the mother’s circulatory system.
The Novalung is a unique type of extracorporeal membrane oxygenation (ECMO) system that uses the patient’s own heart to pump blood through a low resistance membrane – essentially working as an external low-pressure artificial lung. This unique solution was the best option for Candice, as her body and circulatory system changed as pregnancy progressed and the Novalung could adapt to this.
The High-Risk Obstetrics team from Mount Sinai Hospital monitored the baby’s health carefully over seven weeks, as Candice was supported by the Novalung in the TGH Intensive Care unit.
When the developing baby was mature enough to survive, Candice was taken to the TGH operating room, with all the teams participating to perform the delivery while the mother was on ECMO support.
Baby Cameron was born on June 10, 2021. SickKids’ Acute Care Transport Service (ACTS) team was in the OR at TGH and expertly supported the high-risk delivery. After baby Cameron was stabilized, the team transferred him to the NICU at SickKids for continued care. Eight days later, the ACTS team brought Cameron back to TGH to visit his mom in the ICU. Once Cameron was stable enough, he was then transferred to the NICU at St. Michael’s Hospital until he was ready to go home.
In early July 2021*, Candice received a double-lung transplant by the Toronto Lung Transplant Team at UHN’s Ajmera Transplant Centre. She was discharged home a month later. Cameron was discharged from St. Michael’s NICU in early September. The family is now back at their home in Midland, Ont.
*Exact date of transplant is not being published to protect organ donor confidentiality.
“I could feel the baby moving inside me, so strong. I knew there was nothing wrong with him, and I felt he had a good chance. I wasn’t ready to give up.” – Candice Cruise, patient
“We knew we had to prepare for the worst, which was very scary. As her husband, I wanted the safest approach to save Candice, but she kept fighting for our baby. So I put my trust in the doctors here, who are excellent. The whole team was amazing. They didn’t work only to keep Candice and Cameron alive, they really cared.” – Collin Cruise, Candice’s husband
“While we were supporting Candice on the Novalung, we monitored her and the baby every hour of each passing day. We knew if she deteriorated in any way, we would have to move to plan B and have a very early delivery, lowering baby Cameron’s chances of surviving. However, we worked as a team to take her pregnancy safely to the 29-week mark, to save both mother and child” - Dr. Shaf Keshavjee, UHN’s Surgeon in Chief and Director of the Toronto Lung Transplant Program at UHN's Ajmera Transplant Centre.
“Preparing for and attending this high-risk delivery required an immense amount of pre-planning and teamwork with our adult care colleagues. The highly skilled SickKids’ ACTS team has exceptional expertise in resuscitating and stabilizing the sickest infants in the Province. Once stabilized, Cameron was transferred to the NICU at SickKids where he continued to receive high-level care and thrived. A week later, the ACTS team orchestrated a visit back to TGH so that Cameron could be reunited, if only for a short time, with Candice and Collin. Our motto in the NICU at SickKids is ‘every little thing.’” – Dr. Estelle Gauda, Head of the Division of Neonatology at SickKids.
“This case really touched our team. It happened in part during the third wave of the pandemic, when we were losing many young people to COVID. Seeing Candice and her baby have a positive outcome, against all odds, brought joy and a glimmer of hope to everyone involved in their care. ” – Denise Morris, Nurse Manager, Intensive Care, UHN
“We had never seen a case like this. Pulmonary Hypertension is a dangerous condition, even more so for pregnant women, with a high risk of death for both mother and fetus. We are incredibly happy that we were able to combine our expertise to be able to get Candice the support she needed to survive and have a healthy baby.” – Dr. John Granton, respirologist, intensive care physician and Director of the Pulmonary Hypertension Program at UHN.
“As this was a world-first, we had to use all the expertise of our teams to make careful clinical decisions at each step in order to ultimately achieve the best possible outcome.” – Dr. Laura Donahoe, thoracic surgeon at UHN.
“Due to the stress of pregnancy, women with pulmonary hypertension are at very high risk for serious complications, including heart failure. I was really proud to be part of this multidisciplinary team that came together to help Candice get through her pregnancy safely.” – Dr. Candice Silversides, cardiologist specializing in high-risk pregnancy management at UHN and Sinai Health.
“In a complex case like Candice’s, difficult choices need to be made that balance the risks to the mother with the health of the developing baby. The NovaLung presented a novel strategy to support Candice’s heart long enough to carry her pregnancy into the third trimester. This is a remarkable medical success, but by far the most amazing part of this story is how courageously Candice persevered, and how dependably Collin supported her during those challenging weeks.” - Dr. John Snelgrove, maternal-fetal medicine obstetrician, Sinai Health