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Candice Cruise was 21 weeks pregnant when, driving home one day with her husband, Collin, she noticed in the mirror of the car's sun visor that her lips had turned blue. She had been feeling a bit out of breath in recent days, but had dismissed it as something common during pregnancy.
The couple decided to go to the local hospital and get Candice checked.
"It all happened so fast," Candice recalls. "When I look back, it scares me to think what would have happened if we didn't seek help that day."
Candice and Collin could never imagine what lay ahead. For more than four months, away from home, they rode an emotional roller-coaster. There was a fight against a deadly condition for mother and baby; support by a world-first innovation and the dedication of multidisciplinary medical teams at three Toronto hospitals; open-chest surgeries, pre-term delivery and lung transplantation.
It was a long journey complete with a happy ending – mother and baby safe and healthy, and back home.
When Candice arrived at her local hospital with blue lips last April, her oxygenation was so low that the doctors quickly transferred her to Toronto's Mount Sinai Hospital, part of Sinai Health, and the reference centre for high-risk obstetrics.
Shortly after arriving there, the medical team made the call to transfer Candice to Toronto General Hospital for evaluation of a possible devastating heart-lung condition known as pulmonary hypertension. UHN has a comprehensive pulmonary hypertension program and is the provincial lead for extracorporeal membrane oxygenation (ECMO) – a last resource for patients with acute respiratory and circulatory failures.
After confirming the diagnosis of pulmonary hypertension, Candice's condition began to become unstable. A quick decision was required to stabilize her and she was placed on ECMO.
"At that time, doctors told us, unfortunately, that it would be safest to terminate the pregnancy to keep Candice alive," Collin recalls.
However, as Candice stabilized in the hours and days that followed, medical leads from different specialties at UHN, with support from Sinai Health and The Hospital for Sick Children (SickKids), started to ask themselves if anything could be done to save both mother and baby.
"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," says Candice.
"I wasn't ready to give up."
A life-threatening condition
Candice had a condition called pulmonary hypertension, a life-threatening disorder that leads to the narrowing of the arteries in the lungs. This narrowing makes it difficult for the right side of the heart to pump blood through the lungs, which eventually causes the heart muscle to become weak and fail.
The condition is especially dangerous during pregnancy, since the growing baby puts additional stress on the mother's circulatory system.
"We had never seen a case like this," says Dr. John Granton, respirologist, intensive care physician and Director of the Pulmonary Hypertension Program at UHN. "Pulmonary hypertension is a dangerous condition, even more so for pregnant women, with a high risk of death for both mother and fetus."
Most experts recommend that patients with pulmonary hypertension avoid pregnancy given the high risk of death for the mother and her baby. However, Candice was unaware of her condition before she reached 21 weeks of pregnancy.
"Our teams in Respirology, Cardiology, Surgery, Intensive Care, all put their heads together to find a solution and save this mother and baby," says Dr. Shaf Keshavjee, UHN's Surgeon in Chief and Director of the Toronto Lung Transplant Program at UHN's Ajmera Transplant Centre.
"This case is a real testament to how far medical advances and teamwork can go. It is a true medical miracle."
An ingenious plan
Experts from different programs at UHN, including Respirology, Cardiology, Intensive Care, Anaesthesiology, Surgery and Transplant, with support from Obstetrics at Sinai Health and Neonatal Care at SickKids, developed an ingenious plan to keep Candice stable and buy her pregnancy a few more weeks, giving the developing baby the best chance at life.
The solution was to use an adaptable extracorporeal membrane oxygenation (ECMO) system called Novalung – a low resistance membrane that works as an external artificial lung, able to support the heart while also allowing it to continue to pump.
"That was never done before anywhere in the world," says Dr. Keshavjee.
Turns out the system did adapt to Candice's needs as her pregnancy progressed for the following eight weeks.
There were, however, complications along the way. Candice required close monitoring, adjustments to the ECMO settings and some surgical interventions.
"We had to operate on her a few times, and made several bed-side interventions to make sure she was stable enough," says Dr. Laura Donahoe, thoracic surgeon with UHN's Sprott Department of Surgery.
"As this was a world-first, we didn't have any literature to guide us. We had to use all the expertise of our teams to make clinical decisions that we hoped would achieve the best possible outcome."
The partnership with Sinai Health – the lead hospital in high-risk obstetrics – was key to push the envelope and provide Candice the best possible care.
"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," says Dr. John Snelgrove, maternal-fetal medicine obstetrician at Mount Sinai Hospital, who supported Candice's care.
"The NovaLung presented a novel strategy to support Candice's heart long enough to carry her pregnancy into the third trimester," he adds. "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."
At 28 weeks and six days into the pregnancy, Candice remembers the moment she and her care team decided it was time.
"It was getting very hard to breathe as the baby was pushing on my diaphragm," she says. "It was too much, plus all the tubes coming out of me."
Candice was going to be taken to the operating room at Toronto General for her C-section – something extremely rare at TGH because the hospital does not have an Obstetrics Department. But Candice needed to be fully monitored by ECMO experts during her delivery, as she was still being supported by the artificial lung system.
A multidisciplinary team from UHN, Sinai Health and Sick Kids came together to support this high-risk C-section.
"It was so inspiring to see doctors, nurses, and respiratory therapists from these three hospitals come together on such short notice and work cooperatively as one big team," remembers Dr. Snelgrove. "Everybody in the OR played a vital role in the safety of Candice and her baby that day."
Candice had to undergo a general anaesthetic for the C-section, as the team was worried that she would become very unstable during this time and require an increased level of ECMO support. The team prepared Candice for the possibility that they would have to open her chest in order to support her heart through the increased stress of the C-section, which would mean that she would be asleep for at least the first few days of her son's life.
With excellent anaesthesic care, and the ECMO team prepped and ready, the delivery went smoothly and the heart surgery wasn't needed. The doctors woke Candice up and she was able to meet her son, Cameron, in the OR.
"It was like a dream. I was expecting to be out for a few days, so I was confused at first, but it was so amazing," says Candice.
"It was a really special moment," echoes Collin.
While the other teams were caring for Candice, SickKids' highly skilled Acute Care Transport Service (ACTS) team was readying for every possible scenario to support Cameron and transfer him to the neonatal intensive care unit (NICU) at SickKids.
The ACTS team typically has access to specialized neonatal equipment through the nursery at the hospital where the delivery takes place, something not readily available to them at Toronto General. ACTS team members, Jaclyn Murray and Alise Mancini, spent an hour setting up different types of equipment in a separate operating room to ensure they were ready for anything that came up.
Fortunately, the high-risk delivery went smoothly. After stabilizing baby Cameron, the ACTS team expertly transferred him to the NICU at SickKids for continued care. Eight days later, the ACTS team brought Cameron back to Toronto General, where his mom remained in the ICU, for a reunion with his parents.
"Preparing for and attending to high-risk deliveries requires an immense amount of pre-planning and teamwork with our adult care colleagues," says Dr. Estelle Gauda, Head of the Division of Neonatology at SickKids.
The highly-skilled SickKids' ACTS team has exceptional expertise in resuscitating and stabilizing the sickest infants in Ontario.
"Our motto in the NICU at SickKids is 'every little thing,'" says Dr. Gauda.
Once Cameron was ready, he was transferred to the NICU at St. Michael's Hospital of Unity Health Toronto until he was discharged home.
While preemie baby Cameron was recovering well with the great care of Neonatal specialists at Sick Kids and St. Michael's Hospital, Candice wasn't yet out of the woods.
Her condition plus the pregnancy had put a lot of pressure on her heart. Once it became clear that she was not going to improve with medication alone, she was urgently listed for a double-lung transplant.
Unfortunately, because of her relative small frame, it was challenging to find a set of lungs that were a match and could fit her chest.
Around a month later, she got her transplant.
The surgery went well, but soon after there were a few complications.
"There were complications that can happen with any lung transplant, some inflammation, fluids in her lungs," explains Dr. Donahoe, her thoracic surgeon.
"It was touch and go for a few days," she recalls.
For Collin, those hours and days in the surgical waiting room and visiting his unconscious wife in the intensive care unit, were the most stressful of this long journey.
"It was the scariest point for me, a constant terrifying feeling that we could lose Candice at any moment."
With treatment, Candice got better each passing day and her new lungs adjusted to her body. She went home to Midland, Ont. in August. Baby Cameron came home shortly after, in early September.
It takes a village
Candice stayed at Toronto General's Medical Surgical Intensive Care Unit (MSICU) for more than four months. She and Collin say they only got through such a long difficult journey because of the support from friends, family, and especially from members of TeamUHN, Mount Sinai, SickKids and St. Michael's.
"I am just so grateful to all the doctors, nurses, physiotherapists, the whole team. They really were like a second family to me," says Candice.
"I'll never forget any of them."
Denise Morris, Nurse Manager at the MSICU, remembers how the whole team got invested in this case. And how impactful it was, at a time that COVID-19 had taken a big toll on healthcare workers.
"This case really touched our team," Denise says. "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."
While Candice was battling for her life and of her child, Collin was also coordinating the family finances and caring for their first child Caitlyn, who turned 13 a few days after her mother's lung transplant.
"It was a very stressful time for all of our family," he recalls.
Collin and Candice fondly remember physiotherapist Nathalie Cote and her daily efforts to keep Candice in top shape to receive her transplant. They remember nurse Stephanie Bedford who took the time to knit clothes and a hat for the baby; nurse Sharon Cudek, for always taking the time to chat and see how they were doing; nurse Andrea Francis, who worked several nights in a row and kept taking extra night shifts to look after them; nurse Bridgette Ritacca, who supported Candice through difficult moments; and so many others.
"The whole team was amazing," Collin says.
"They didn't work only to keep Candice and Cameron alive, they really cared."