A 23-year-old woman pregnant with her first child already knew her vocal cords did not always behave. Then her breathing trouble escalated into an emergency that required a breathing tube, followed by a cesarean delivery performed at her bedside in the intensive care unit.
During that surgery, doctors made another unexpected discovery: her placenta had begun separating from the uterus.
The case, published Sept. 12 in the American Journal of Case Reports by an author team that includes members of the University of Kentucky's Division of Obstetric Anesthesia in Lexington, describes an airway emergency associated with paradoxical vocal fold motion (PVFM) and placental abruption. The authors note that limited data exist on how PVFM behaves during pregnancy.
When the Vocal Cords Close at the Wrong Time
PVFM is a condition in which the vocal cords move the wrong way, closing when they should open during breathing. The authors describe it as a rare disorder of episodic upper airway obstruction that causes recurrent stridor, a high-pitched, noisy breathing sound, and respiratory distress.
According to the Merck Manual, the resulting obstruction is often mistaken for asthma. The condition is more common in women ages 20 to 40, and while its cause is unclear, it has been associated with anxiety, depression, and post-traumatic stress disorder. It is not considered a condition that patients produce consciously. Treatment typically centers on education, counseling, and speech therapy that teaches special breathing techniques, and severe cases have rarely required a tracheostomy.
The American Speech-Language-Hearing Association now uses the broader term inducible laryngeal obstruction, noting that episodes can be triggered by irritants, stress, or exercise; that an estimated 25% of adults with asthma also have the condition; and that speech-language pathologists play a central role in diagnosis and treatment.
The resemblance to asthma can delay diagnosis. In a case report published in 2023, a young woman repeatedly sought emergency care and was treated for asthma attacks without lasting relief. A flexible laryngoscopy, which lets doctors watch the vocal cords move, eventually revealed the problem, and she improved significantly with care from speech therapy, pulmonology, and psychiatry.
The disorder is not limited to adults. Last October, the same journal described PVFM in a newborn diagnosed at 18 days of life with feeding difficulties and noisy breathing, noting that no universally accepted guidelines exist for diagnosing the condition in newborns. The baby's feeding gradually improved, and a repeat laryngoscopy later showed normal vocal cord movement.
From Botox Injections to an ICU Delivery
The woman had a known history of PVFM and underwent botulinum toxin injections into both vocal folds, according to the published abstract.
One week after a hospital discharge, she was readmitted with recurrent stridor. Her symptoms improved temporarily with treatment, but she then developed acute respiratory distress severe enough to require a breathing tube.
Monitoring then showed non-reassuring fetal heart tones, a sign the baby might be in distress. Doctors performed an emergency cesarean delivery at the bedside in the ICU, and during the operation they found a placental abruption that had not been suspected.
The published abstract does not report the pregnancy's gestational age, the baby's outcome, how the airway was secured, or how the mother recovered.
Pregnancy May Make Airways Harder to Manage
The authors suggest that the anatomical and physiological changes of pregnancy may worsen PVFM, creating challenges for emergency airway management outside the operating room.
They also suggest an association between acute flare-ups of chronic PVFM and placental abruption. They conclude that pregnant patients with PVFM should be closely monitored and considered at increased risk of difficult emergency airways and of maternal respiratory distress, which the authors believe can lead to abruption.
That proposed link rests on a single patient. A case report cannot establish that PVFM episodes cause placental abruption, and the abruption in this case was discovered incidentally during surgery.
Abruption Can Hide Behind Another Emergency
Placental abruption is the separation of the placenta from the uterine wall before the baby is delivered. According to a review in the American Journal of Obstetrics & Gynecology, it complicates 0.6% to 1.2% of pregnancies. The review notes that a concealed abruption may cause abdominal pain and contractions without obvious vaginal bleeding, and that severe cases can trigger a dangerous clotting disorder with potential for serious maternal illness and death.
In this case, the abruption came to light only because the team was already delivering the baby for signs of fetal distress, a reminder that one emergency can mask another.
For pregnant patients, the Kentucky report suggests that a known history of vocal cord dysfunction should be shared early with obstetric and anesthesia teams so they can plan for potential airway challenges.
Anyone who is pregnant and experiences noisy breathing, throat tightness, or difficulty inhaling should seek prompt medical care. Vaginal bleeding, abdominal pain, or reduced fetal movement also require immediate evaluation.
Key Questions Answered
What is paradoxical vocal fold motion?
It is a condition in which the vocal cords close when they should open during breathing, causing noisy breathing and respiratory distress that can resemble asthma.
What happened to the patient?
A 23-year-old in her first pregnancy with known PVFM developed respiratory distress requiring a breathing tube, then underwent an emergency ICU cesarean because of signs of fetal distress.
What was discovered during the cesarean?
Doctors unexpectedly found a placental abruption, in which the placenta separates from the uterus before delivery.
Does PVFM cause placental abruption?
The authors suggest a possible association, but a single case cannot prove that one causes the other.
What should pregnant people with PVFM do?
They should share their history with their obstetric and anesthesia teams and seek prompt care for breathing difficulty, bleeding, or abdominal pain.
