Pregnant Patient with Eclampsia for Emergency Cesarean Section

Case File
https://medical-phd.blogspot.com/2021/03/pregnant-patient-with-eclampsia-for.html

Lydia Conlay, MD, PhD, MBA, Julia Pollock, MD, Mary Ann Vann, MD, Sheela Pai, MD, Eugene
C. Toy, MD

Case 35
A 40-year-old G3P2002 woman, at 383/7 weeks’ gestation, was admitted in early labor. During her
prenatal course, she had been diagnosed with pregnancy-induced hypertension (PIH). On
admission, her BP was 155/96 mm Hg, HR 110 beats/minute (bpm), and she had +2 pedal edema.
Her hemoglobin was 9.8 g/dL, platelet count was 117, 000/mm3, and urinalysis showed 2+
proteinuria. Her laboratory tests were otherwise normal. She was started on infusions of oxytocin
and magnesium.

Shortly after admission, the patient complained of a headache. Her blood pressure was noted to be
166/101 mm Hg, signs of fetal distress were noted on the monitor, and the anesthesiologist was
notified of the urgent cesarean section. As the operating room team was being mobilized, the
obstetrician noticed an acute change in the patient’s mental status, followed shortly thereafter by a
tonic-clonic seizure.

➤ What are the pathophysiological alterations in preeclampsia and their implications on the
anesthesia for cesarean section?

➤ What anesthetic modalities are utilized for emergency cesarean section in PIH?

➤ What are the effects of the anesthetic management on PIH?

ANSWERS TO CASE 35:

Pregnant Patient with Eclampsia for Emergency Cesarean Section

Summary: A 40-year-old G3P2002 woman at 383/7 weeks’ gestation with severe PIH and seizure
requires emergency cesarean section.

➤ Pathophysiological alterations with preeclampsia: Preeclampsia can present with elevated blood
pressure, proteinuria, pulmonary edema, elevated liver function tests, thrombocytopenia, and
neurologic dysfunction, including seizures. These alterations may have significant impact on the
anesthetic plan.

➤ Anesthetic modalities in cesarean: General and neuraxial regional anesthesia may be used for
cesarean section in PIH. The choice of anesthetic technique depends on the specific patient
presentation and the severity of the organ system dysfunction.
➤ Effects of anesthesia: Use of general anesthesia may be associated with rapid swings in blood
pressure during airway manipulation. Additionally, the incidence of difficult airway is increased in
the presence of both pregnancy and exacerbated by PIH. Use of neuraxial blockade in the presence
of thrombocytopenia may be associated with epidural hematoma and neurological complications of
the hematoma.

ANALYSIS

Objectives
1. Understand the pathophysiology and the clinical presentation of PIH.
2. Understand the implications of eclampsia and preeclampsia for the anesthesia management.
3. Identify the benefits and risks of general and regional anesthesia for emergency cesarean section
and develop a plan for anesthesia and intraoperative monitoring.
4. Manage the perioperative complications during cesarean section of a patient with eclampsia.

Considerations
This patient’s BP is well controlled with a signal agent (magnesium). Her laboratory results do not
show evidence of end-organ damage which could result from her chronically elevated blood
pressure. But the onset of seizures with loss of consciousness on day of presentation makes this an
emergent situation requiring immediate c-section.

Given, the emergent nature of the procedure, general anesthesia with rapid-sequence intubation is
the anesthetic of choice. Nevertheless, an exaggerated hypertensive response to laryngoscopy,
and/or to the administration of exogenous vasopressors should be anticipated. The airway changes
in pregnancy are further compounded by PIH and edema, and may result in difficulty at intubation.
The patient’s intravascular volume could be normal, or even markedly reduced from chronic
vasoconstriction, further contributing to the considerable hemodynamic lability. Intravenous (i.v.)
fluids should be administered judiciously to avoid the risks of fluid overload, congestive heart
failure, and even pulmonary edema. Magnesium and beta-blockers, treatments for PIH, add to the
risk of heart failure. She is receiving the definitive treatment for PIH, which is delivery of the fetus.

APPROACH TO
Pregnant Patient with Eclampsia

DEFINITIONS
PIH: It includes a spectrum of disorders from isolated hypertension to hypertension associated with
multiorgan dysfunction (preeclampsia) and seizures (eclampsia).

HELLP SYNDROME: It is a severe form of preeclampsia that includes hemolysis, elevated liver
enzymes and low platelet count.