Four-in-one surgery in a 33-week pregnant patient with pseudo-angina Ludovici and mediastinal extension: a case report

Ludwig’s angina is a deep neck and mouth floor infection that involves the submandibular and sublingual space and could spread inferiorly into the mediastinum. Life-threatening complications of Ludwig’s angina are airway obstruction and septic shock. Here we present a case of a 30-year-old woman who presented at 33 weeks pregnant with Ludwig’s angina, mediastinitis, and an impacted lower second and third molar. The patient underwent four surgeries consecutively, including caesarean delivery, surgical drainage of the submandibular and submental areas, thoracotomy, and odontectomy. On the first postoperative day, the patient had septic shock, and a sepsis bundle was implemented. However, the condition continued to deteriorate, and the patient passed away on the fifth day of care. Disease outcome varies between patients; therefore, the management approach should be individualized. Comprehensive multidisciplinary collaboration between an anesthesiologist, otolaryngologist, cardiothoracic surgeon, obstetrician-gynecologist, and oral-maxillofacial surgeon is crucial to reduce the risk of materno-fetal morbidity and mortality. Abbreviations: LEMON: Look - Evaluate - Mallampati class - Obstruction - Neck (an acronym for the assessment of the airway’s appearance, identification of any dental issues, evaluation of Mallampati classification, assessment of airway obstruction, and examination of neck mobility), MOANS score: Mask seal - Obesity / Obstruction - Age (>55) - No teeth - Sleep apnea / Stiff lungs Keywords: Pregnancy, Ludwig’s angina, septic shock, airway management Citation: Tanoto C, Kurniyanta IP, Senapathi TGA. Four-in-one surgery in a 33-week pregnant patient with pseudo-angina Ludovici and mediastinal extension: a case report. Anaesth. pain intensive care 2025;29(6):646-650; DOI: 10.35975/apic.v29i6.2934 Received: June 16, 2025; Revised: July 07, 2025; Accepted: July 28, 2025