Lying on her hospital bed, a blanket pulled over her pregnant belly, Candice Cruise thought she was dying.
Her vision was blurry. Her hearing felt off. And even with machines pushing 100 per cent oxygen into her lungs, each breath was a desperate suck for air.
Earlier that day doctors had told Candice she had pulmonary hypertension, a rare condition caused by narrowed arteries in her lungs that forced her heart to work dangerously hard.
To survive, the 37-year-old would need new lungs. And medical guidelines recommended doctors end her 21-week pregnancy to save her life.
But first, before either of those last-resort interventions could be considered, surgeons at Toronto General Hospital had to put Candice on a sophisticated life-support machine to get more oxygen into her lungs.
Clutching his wife’s hand, Collin Cruise tried to tamp down his fear. He had raced to the city from their home in Midland, a town 50 km north of Barrie, leaving their then-12-year-old daughter with family.
Now, watching Candice struggle to breathe, he wondered whether they would all be together again.
“I didn’t think it would turn out very good,” he said, recalling the moment Candice was wheeled into the operating room. “I thought I was going to lose her.”
Candice survived that April surgery. It was the first of many fear-filled nights and the beginning of a medical case that would test the skills and daring of a physician team willing to push boundaries to save the lives of a mother and her unborn baby.
Doctors at Toronto General, Mount Sinai Hospital and the Hospital for Sick Children believe Candice’s case is the first in the world where a pregnant mother with advanced pulmonary hypertension safely continued her pregnancy with the help of a unique heart-lung machine and a series of other life-support techniques.
The machines oxygenating her blood allowed Candice to carry her son for an additional eight weeks; Cameron was born 11 weeks premature but otherwise healthy. A month later, after a 14-hour transplant surgery, Candice had new lungs. Both mother and baby are now home. Cameron is rarely out of Candice’s sight.
Doctors involved in this case say it is among the most challenging of their careers. With no others like it in the world, they had to map their own course, relying on their collective expertise to extend the limits of what had been done before.
That the case unfolded during the height of Ontario’s third pandemic wave, when the hospital’s intensive care unit was crowded with COVID patients, makes their success even more remarkable.
Candice, whose own mother had pulmonary hypertension and died at a young age, hopes her story will help others faced with similarly dire diagnoses.
“One of the hardest parts was not knowing if it would all work out,” she said. “I was always so scared.
“I really wanted this baby. I could feel him moving around; I was attached. But I also needed to make sure that I came home to my daughter. I didn’t want to leave her behind, I didn’t want her to be without a mother.
Candice first suspected something was wrong in January, just weeks after learning she was pregnant.
She was unusually tired at the end of her workday cleaning homes and cottages in the Georgian Bay community and often felt dizzy. Twice, her heart pounded so hard and so fast she went to the local hospital. But both times doctors said she was suffering from anxiety and told her not to worry.
Her obstetrician, too, chalked up her worsening symptoms to the fatigue typical in pregnancy.
But by April, Candice was out of breath just walking from the dining room to the kitchen sink. She called her family physician when her lips turned blue.
“It was the first time I was taken seriously. He said: ‘I want you to go to the emergency department, and I want you to go right now.’”
She was nearly 21-weeks pregnant.
Doctors at Georgian Bay General Hospital decided to transfer Candice to Mount Sinai’s high-risk pregnancy unit. In the ambulance, paramedics fought to keep her oxygen levels from plummeting.
Shortly after arriving at Mount Sinai, Candice was again moved, this time across the street to the cardiac clinic at Toronto General, part of the University Health Network. After a series of tests, doctors found a small hole in her heart and confirmed she had pulmonary hypertension.
Dr. John Granton, a respirologist and director of UHN’s pulmonary hypertension program, said it is rare to make such a diagnosis midway through pregnancy and just as rare to see a patient decline so fast. He tried to be gentle as he delivered the news to Candice.
“I told her she had a life-threatening condition; that we were probably going to have to terminate the pregnancy; that she was going to have to go on life support and that she might die,” he said.
“So, three hits, and she just took it, and said: ‘I understand; let’s just do what we have to do.’”
Within hours, Candice was wheeled into an operating room to be put on ECMO, or extracorporeal membrane oxygenation. This version of life support removes carbon dioxide and adds oxygen from blood that has been siphoned from a patient’s vein near the groin. It then pumps the oxygenated blood back into another vein near the patient’s heart, essentially replacing the lungs.
The machine is typically used to buy time for critically ill patients waiting for a lung transplant, or to allow a patient’s lungs to heal after being severely damaged by an infection.
For Candice, it wasn’t enough.
In the days that followed, her blood pressure repeatedly dropped to dangerous levels. A few times, doctors thought she would die.
“Somebody with pulmonary hypertension can suffer sudden death because their heart just fails,” said Dr. Laura Donahoe, a thoracic surgeon at UHN. “That was what we worried about with Candice; we needed to off-load the pressure on her heart.”
But even as doctors plotted their next steps, Candice made it clear she wanted to stay pregnant for as long as possible.
Typically, patients with pulmonary hypertension are advised not to get pregnant. The stress from a growing fetus puts too much pressure on the already strained circulatory system, placing the lives of both the mother and her unborn baby at risk.
When patients are diagnosed with the condition while already pregnant, doctors sometimes recommend terminating the pregnancy if the chance of death for the mother is just too great should she continue carrying a baby.
After an hours-long conference call, the team of specialists overseeing Candice’s case decided they would try to extend her pregnancy by implanting a unique artificial lung device called a Novalung in her chest. They believed it was their best chance to keep her pregnant. They also knew there was no guarantee it would work.
“It was really hard; there was no similar case in the medical literature,” said Donahoe. “We spoke to other experts from around the world, and nobody knew of any similar situations.
“We had to use all of our collective expertise to make the best judgment possible.”
Dr. Shaf Keshavjee, Surgeon in Chief at UHN, thought the Novalung would help pull Candice through her pregnancy because it was the life-support device that would put the least amount of stress on her heart. This was a key consideration; as her pregnancy progressed, her heart would have to work harder and harder to pump an ever-increasing volume of blood to her growing baby.
“We could adapt the Novalung to her pregnancy,” said Keshavjee, director of the Toronto Lung Transplant Program at the hospital’s Ajmera Transplant Centre. “And if it didn’t work, if she got at all unstable, we could go back to the original plan of aborting the pregnancy.
“At 21 weeks of pregnancy, aborting the baby, he would have died. But if we could get her to 23 or 24 weeks pregnant — or even longer — before she got unstable, at least we were giving the baby a chance, which is what Candice wanted.”
Donahoe and her team connected Candice to the Novalung during a lengthy, open-chest surgery. When Candice awoke from the anesthetic, she saw two blood-filled tubes emerging from her chest. One drained blood from the pulmonary artery on the right side of her heart, feeding it into the Novalung. The other sent blood oxygenated by the device back into the left side of her heart.
This time, the life support worked. Candice’s condition stabilized and soon she was able to sit up in bed. Before, she had been so weak she could not write her own name.
Still, there were setbacks. Her blood pressure was often erratic. The team constantly had to adjust medications and the Novalung to keep up with her advancing pregnancy. Often, Donahoe worried Candice’s heart would fail.
An obstetrics team from Sinai monitored her growing baby. Each passing week increased the odds of his survival. Amazingly, he continued to do well.
Through it all, Collin came to Toronto General every day. He was on leave from his job as a swamper — a construction worker who directs tower cranes from the ground — with the crews building the new research tower at the Hospital for Sick Children.
Many nights, Collin slept in his car to stay close to Candice. He parked in gas stations and outside convenience stores, avoiding the hospital’s underground lot; he needed a reliable cell signal in case the hospital called to tell him Candice was in trouble.
When he wasn’t at her bedside, Collin spoke to Candice on the phone. The couple — married for 14 years and together an additional four — found it hard to be apart.
“We’d leave our phones on all night,” Candice said.
“That way,” added Collin, “we’d still feel like we were together all the time.”
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After 48 days in hospital, Candice was 27-weeks pregnant and well enough to go outside. Her physiotherapist wheeled her to the sidewalk and surprised her with a small cup of chocolate gelato.
“That was the best day. I just sat and took it all in. I won’t ever forget that feeling of the sun warming my face.”
Walking into the ICU on a Thursday morning in June, Donahoe couldn’t shake her worry.
She’d been alerted that Candice’s blood pressure had plunged overnight. And though Candice had bounced back from such extremes before, this time felt different.
“She was just that little bit worse,” Donahoe said. “I assessed her. I talked to the ICU staff and the other doctors. And we said, ‘OK, now is the time to proceed with the delivery.
“That was stressful; we knew that two lives were at risk.”
Within three hours, teams from UHN, Sinai and Sick Kids had gathered near a pair of operating rooms at Toronto General. One was being prepped for Candice’s caesarean section, the other set up to provide emergency care to her baby.
Though she had managed on the Novalung — and made it to almost 29 weeks pregnant — Candice now faced a new danger.
For most women, a caesarean comes with few risks. But for those with cardiac conditions, including pulmonary hypertension, a C-section birth puts an enormous strain on the heart and circulatory system, said Dr. John Snelgrove, a maternal-fetal medicine obstetrician from Sinai who monitored Candice throughout her pregnancy.
“Suddenly, the baby is no longer inside. And suddenly, the uterus is no longer needing 25 per cent of the body’s blood volume anymore. Transfusing that huge amount of blood back into circulation all at once? The heart muscle is able to compensate for that in normal situations, but not in a situation like Candice’s.”
Before the surgery, Donahoe prepared Candice for yet another kind of life-support machine. It would only be used if her heart failed.
“The surgeons were ready to open her chest and commence even more invasive extracorporeal life support,” Snelgrove said. “On the table for my surgical instruments that I use for a C-section there was a sternotomy saw. It was a pretty surreal scenario.”
Collin had stayed with Candice until she was taken to the operating room. Then, he went outside to wait.
He walked down the street and found a quiet place to sit on the front lawn of Sick Kids. His brother, also a swamper at the Sick Kids construction site, soon joined him on the grass.
“When I got his text, I left work to be with him,” said Kevin Cruise. “I just sat with him. I wanted to be there in case something happened, so he wasn’t alone.
“There was a real chance they could lose the baby, or he could lose Candice. It wasn’t right for him to sit there by himself.”
After a couple hours, a nurse texted Collin that all had gone well.
“I hugged him,” Kevin said. “Then I told him to go and meet his son.”
Back in the operating room, the team was making a decision. They had planned to keep Candice asleep, possibly for up to four days, to allow her body to safely adjust to giving birth.
But the anesthesia team said she made it through surgery better than expected. They thought they could wake her up to see her baby before he was transferred to Sick Kids through the tunnels that connect the hospitals on University Avenue.
“They ended up surprising me with Cameron,” said Candice, whose son was born on June 10 weighing two pounds, four ounces.
For the medical team who had agonized over her case it was a beautiful moment.
“When she put her hand in his incubator to touch him every single person in the room was crying,” said Snelgrove.
Candice next saw Cameron eight days later when staff from Sick Kids’ Acute Care Transport Services team wheeled him into her ICU room at Toronto General.
Just one day earlier she had asked to go see him. She had sobbed when Donahoe said she was too unwell to make the short trip.
Holding Cameron in her arms, Candice felt the worry in her chest ease. Gently, she touched his toes. Before handing him back, she told him she loved him one more time.
Weeks passed and the transplant team still waited for a suitable pair of donor lungs for Candice.
The organs needed to match her blood type and come from a donor with a similar body size; Candice is just 5’ 1” and after months in hospital weighed less than 100 pounds.
Though she had known since April she needed new lungs, Candice was terrified of the transplant procedure. Her mom, critically ill with pulmonary hypertension, died two weeks after undergoing lung transplant surgery when her body rejected the organs. It was 1995 and Candice was just 11 years old.
“Almost the same age as my daughter is now. That’s why I was afraid; I didn’t want to die and leave her. I know what it’s like to be without a mom.”
After Cameron was born, Candice’s fear of a transplant waned. She was still so sick and she knew getting new lungs was the only way she could go home.
“I wanted to be with my family. And the doctors kept telling me that a lot is different now with transplants, that they know so much more than they did back when my mom died.”
Except for three visits with her daughter, Caitlyn — including one on Mother’s Day — Collin was the only family member allowed at her bedside due to COVID restrictions at the hospital.
In the neighbouring rooms, critically ill COVID patients lay sedated and hooked up to life-support machines. At one point, there were 27 COVID patients on ECMO. Not all of them lived, and Candice says it was horrible to hear the cries of a grieving family saying goodbye.
In early July, Candice was matched with a pair of donor lungs. The transplant and critical care teams prepared for yet another risky surgery. By chance, Donahoe was on call that day.
It took 14 hours to transplant the donor lungs into Candice’s chest. Scar tissue from each of her previous surgeries made the difficult procedure even tougher than usual. And the team had to rush to put Candice back on ECMO following the transplant when it looked like her new lungs were starting to fail.
“I remember thinking, ‘Oh my gosh, we’ve done all this and now she’s going to die?’” Donahoe said.
After more than four months in hospital, and weeks of rehabilitation, Candice went home on July 29. Cameron joined them on Sept. 3.
“I felt like we were complete at that point,” Candice said. “It was what we’d been working for, what we’d been fighting for.”
Candice’s doctors say she is among the most inspiring patients they’ve met; they are in awe of her quiet strength.
“I can’t imagine all that she was going through,” said Granton. “But she just threw all her trust with us; it’s incredible she did that.”
Candice and Collin are now enjoying the things that seemed impossible while she was on life support in hospital and Cameron’s life was in danger. Taking their dog — a golden retriever named Autumn — to swim in a nearby lake. Eating home-cooked dinners together with Caitlyn. Sitting around a campfire in the cool evenings with friends and family.
Looking back on Candice’s case, Snelgrove said the stakes couldn’t have been higher for a pregnant mother.
“There’s no condition that I can think of that would be worse,” he said. “There are conditions that are similarly bad. But when you open a textbook to pulmonary hypertension, it’s classified as a situation that is contraindicated in pregnancy, or pregnancy is contraindicated if somebody has this condition.
“I wrapped myself into knots thinking about this case because there was no zero-risk alternative, there was no way I could tell Candice: ‘This is the safest option for you.’ Because at any point in time, with any intervention we did, there would be challenges.”
Donahoe hopes colleagues in other hospitals will learn from this case. That patients with pulmonary hypertension won’t always have to be in the heart-wrenching position of ending a pregnancy to save their own life.
“What does that kind of decision do to a person who is pregnant? What if that pregnancy is their last chance to have a baby?” she said.
“Maybe Candice’s case will allow another woman to have a healthy baby and survive her pregnancy. Maybe it will give someone else some hope.”
Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie
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