ABSTRACT Due to the rarity of cerebrovascular diseases in pregnancy, there are no definite guidelines for the choice of anesthetic

technique for cesarean section of a pregnant woman with cerebral arteriovenous malformation. Reporting a case of anesthetic management of cesarean section of a pregnant woman with subarachnoid hemorrhage secondary to ruptured arteriovenous malformation diagnosed at the 14th week of gestation. The patient was managed medically and was scheduled for elective cesarean surgery once full term, however, she was admitted to the hospital urgently at the 39th week of gestational age and emergency cesarean section with bilateral tubal ligation under subarachnoid block was performed successfully. Considering optimal maternal and fetal well being, subarachnoid block can be used satisfactorily for emergency cesarean section with bilateral tubal ligation of a pregnant woman with Anesthetic management of emergency cesarean section with bilateral tubal ligation of a pregnant woman with subarachnoid hemorrhage secondary to ruptured arteriovenous malformation, Left temporal lobe, Hunt Hess Grade I.

INTRODUCTION

Cerebrovascular diseases are quite rare in pregnancy [1]. Cerebral arteriovenous malformations (AVM) are present in approximately 1:10.000 of the population and are responsible for approximately 10% of subarachnoid hemorrhages in general population [2]. Intracranial hemorrhage due to rupture of an AVM during pregnancy is a rare but serious condition; when it occurs, both the mother's and the fetus's well-being is effected [3]. The choice of anesthetic technique for Caesarean section of these patients is made to maintain a stable cardiovascular system [4], but due to the rarity of this condition, no definitive guidelines exist. Anesthetic considerations during pregnancy are governed primarily by maternal-fetal physiology and arterial pressure control to reduce the risk of aneurismal hemorrhage.

CASE PRESENTATION

Reporting a case of anesthetic management of emergency cesarean section with bilateral tubal ligation of a pregnant woman with subarachnoid hemorrhage secondary to ruptured arteriovenus malformation. A 31 year old gravida three para two at the 14 th week of gestational age was admitted in our institution with complaint of severe headache. History revealed that the patient experienced severe on and off headache of one week duration, crushing in character with moderate to severe intensity, associated with vomiting, undocumented fever and irritability. There was no seizures, loss of consciousness, and body weakness or numbness noted. Consult was sought at Candon Hospital where she was initially managed as a case of to consider meningitis, rule out space occupying lesion due to noted nuchal rigidity and change in

sensorium upon admission. Cranial CT scan was done revealing intracerebral hemorrhage with intraventricular extension, cerebral edema and prominent lateral ventricles to consider ruptured AV malformation versus aneurysm. The patient was then given 150cc intravenous bolus of Mannitol, a single dose of 500mg intravenous Tranexamic Acid, four doses of 1g intravenous Ceftriaxone every 12 hours and 500mg of oral Paracetamol every four hours. The patient then opted to transfer to our institution for further evaluation and management. Examination at the emergency room revealed the patient to be conscious, coherent not in cardio-respiratory distress with initial vital signs blood pressure of 90/60, CR 64 beats per minute, RR 16 breaths per minute and temperature at 37C. The patient still complained of moderate to severe headache and had a Glaslow Coma Scale of 15 (M6V5E4) Past medical history and family history of the patient was unremarkable. The patient is a gravida 3 para 2 (2002) 0n her 13th week age of gestation, a nonsmoker, non alcoholic, with previous use of oral contraceptive pills. Pertinent physical examination findings was neck rigidity. The neurologic exam was normal, no motor and sensory defects noted, no abnormal reflexes noted. The patient stayed in the hospital for 19 days attended by a neurologist, neurosurgeon and obstetrician. Venoclysis with PNSS 1 liter x 30gtts/min and received 150cc in intravenous mannitol every four hours, tapered down to 100cc every 6 hours then 50cc every 4 hours. She also received Nimodipine 20mg/tab 2 tablets every four hours, Lamotrigine 50mg/tab once a day, Paracetamol 500mg/tab every four hours, Citicoline 500mg/tab once a day and multivitamins 1 capsule once a day. CT angiography of the head was done revealing possibility of arteriovenous malformation, left temporal lobe, hypoplastic right vertebral artery and a repeat cranial CT scan revealing regression of intraparenchymal bleed at 7cc. The rest of the hospital stay was unremarkable. The final diagnosis was Subarachnoid hemorrhage secondary to ruptured arteriovenous malformation, Left temporal lobe, Hunt Hess Grade I, G3P2(2002) Pregnancy Uterine, 14 weeks age of gestation, not in labor. She was scheduled to undergo elective

cesarean section with bilateral tubal ligation under subarachnoid block once full term and was advised to avoid strenuous physical activities, limit straining and have regular follow up checkup. At 33weeks AOG, the patient came for follow up and for pre-anesthetic evaluation. She has no complaints of headache, dizziness and vomiting, was conscious, coherent, not in cardiorespiratory distress with normal neurologic exam, no motor and sensory defects noted, no abnormal reflexes noted. The patient was classified as ASA III, and was advised to repeat cranial CT scan. The patient was admitted to the hospital at the 39 th week of gestational age, urgently with uterine contractions and no complaints of headache, dizziness or blurring of vision. Internal examination revealed the cervix to be 6-7cm dilated, 70% effaced, cephalic, station -3 with intact bag of water prompting an emergency caesarean section with bilateral tubal ligation under subarachnoid block be done immediately. The patient was pre-medicated with an intramuscular cocktail of 25 mg Promethazine and 10 mg Nalbuphine and intravenous cocktail of 10 mg Metoclopromide and 50 mg Ranitidine immediately prior to induction of anesthesia. Initial vital signs at the OR are as follows, BP of 110/61, heart rate of 70 and O2 saturation of 95% at room air. Maternal monitoring consisted of the standard monitoring of anesthesia, mean arterial pressure, heart rate, and peripheral O2 saturation measured before the induction, every 5 minutes after the induction until the end of the surgery. Preloading of 500cc D5LRS was done prior to induction of anesthesia. The patient was put in a left lateral decubitus position and the lumbar area was prepped with povidone iodine. Anesthetic technique was subarachnoid block at the level of L3 and L4, paramedian approach, single attempt, using a gauge 25 spinal needle with note of clear, free flowing cerebrospinal fluid and absence of paresthesia. The local anesthetic used was 10 mg Bupivacaine hyperbaric with 0.2 mg morphine. Block was determined up to the level of T6. and an indwelling foley catheter was inserted aseptically.

Surgery started 11 minutes after the induction of anesthesia, 10 IU oxytocin was incorporated to 1L D5LRS as IV fluid upon baby out and 200mg of intravenous Methylergometine maleate was given upon placenta out. The operation, which lasted for 64 minutes, was unremarkable, with stable vital, signs no sudden drop or increase in blood pressure, blood loss of about 500cc and urine output of about 300cc. In the recovery room, the patient was maintained in NPO and was instructed to remain flat on bed for 8 hours. Oxygen via face mask was given at 2-3 liters per minute. Post-operative pain medications included 4 intravenous doses of 30 mg Ketorolac every 6 hours and 6 intravenous doses of 5 mg Nalbuphine every 4 hours. Three doses of the anti-emetic Metoclopromide 10 mg were given intravenously every 8 hours and 10 mg of intravenous Diazepam standing order for seizures. The patient was the observed for signs of postdural puncture headache, increased intracranial pressure, decreased level of sensorium and seizures. The patient was then transferred to the ward with stable vital signs. On the 1st post-operative day, the patient had no complaints of headache or pain on the operative site. she was put on soft diet once with bowel movement and all intravenous medications were shifted to oral medications; 625mg Co-amoxiclav every 12 hours, 500mg Mefenamic Acid every 6 hours, 37.5mg Tramadol + 325mg Patacetamol every 8 hours and Ferrous fumarate +Folic Acid + vitamin B2 B12 once a day. Sublingual 75mcg of Clonidine was on standby for BP greater than 140/90. Early ambulation was encouraged, but with limited physical straining. The rest of the patients hospital stay was unremarkable and she was discharged improved after four days.

DISCUSSION

Cerebrovascular diseases are quite rare in pregnancy [1]. Cerebral arteriovenous malformations (AVM) are present in approximately 1:10,000 of the population and are responsible for approximately 10% of subarachnoid hemorrhages (SAH) in general population [2]. Intracerebral hemorrhage (ICH) is due to SAH from ruptured aneurysms (65%), bleeding from AVMs (35%),[3] and other very rare causes.[4] The incidence of ICH is approximately 10 50 in 100,000 deliveries [5]and ICH accounts for 7% of pregnancy-related maternal mortality. [6] During pregnancy, SAH carries a sinister prognosis, with a 35% risk of fatal maternal outcome [4] and a 25% fetal mortality rate. [7] Most cases of SAH are caused by the rupture of an intracranial aneurysm, an event thought to occur more frequently during pregnancy (approximate incidence 20 in 100,000 pregnancies). [3,5] The time of hemorrhage due to AVM in pregnant women is most common at the 15th20th weeks in younger patients but bleeding may occur at any stage including during labor or in the puerperium [8] and the maternal mortality is approximately 20%. Whether pregnancy is a risk factor for hemorrhage from AVMs is controversial. The increased risk of aneurysm rupture during pregnancy has been explained by a pregnancyinduced increase in circulating blood volume and cardiac output, and the hormonal changes to the arterial wall. [9] Some studies suggest that that pregnancy does not confer an increased risk of hemorrhage in women harboring an AVM;[3] however, the risk of rebleeding is 25% during the same pregnancy, compared with a 3%6% risk during the first year in nonpregnant women. Others believe although there may be an increased risk of aneurysm rupture around the time of delivery, [10] parity confers a moderate long-term protective effect on the risk of SAH. [11] The uterine contractions of labour and the Valsalva effect of vaginal delivery are accompanied by dramatic, transient increases in venous pressure, cardiac output, and cerebrospinal fluid pressure. For this reason, Caesarean section is recommended for patients with inoperable AVMs [12]

The Intracranial hemorrhage due to rupture of an AVM during pregnancy is a rare but serious condition; when it occurs, both the mother's and the fetus's well-being is effected [12]. AVMs during pregnancy may present with severe headache, meningism and photophobia and can be confused with eclampsia. [13] The confirmation of the diagnosis is made by computed tomography (CT) or lumbar puncture and cerebral angiography. [13] A repeat study may also be done to assess and monitor whether there are changes in the affected structures. These follow up studies could help in the management strategies, whether medical or in the anesthetic sense. The patient was given an intravenous cocktail of 10 mg Metoclopromide and 50 mg Ranitidine immediately prior to OR. Although not supported by good levels of evidence, aspiration and vomiting prophylaxis is considered to be important before anesthesia during pregnancy, because pregnant women are more likely to experience both symptomatic and silent regurgitation [14] and an increase in intracranial pressure caused by vomiting can be dangerous, risking rebleeding and cerebral hypoperfusion [15] The most important problem in anesthetic management for the pregnant that has an emergency Caesarean section and AVM is the acute subarachnoid hemorrhage due to the intraoperative rupture caused by hypertension. The choice of anesthetic technique for Caesarean section of these patients is made to maintain a stable cardiovascular system and is decided on a case to case basis [15], but due to the rarity of this condition, no definitive guidelines exist. So far various regional anesthetic techniques volatile anesthetics and antihypertensive agents have been used. However, it is impossible to select one of these methods as precisely superior to the others since most of the studies were merely case presentations. Anesthetic considerations during pregnancy are governed primarily by maternal-fetal physiology and arterial pressure control to reduce the risk of aneurysmal hemorrhage. Anesthetic goals for these patients included fetal and maternal well being.

The woman should be cooperative, and preferably have normal ICP. This approach allows the woman to see her baby at birth and reduces the risk of life-threatening anesthesiainduced morbidity and mortality. [16] The patient was also pre-medicated with an intramuscular cocktail of 25 mg Promethazine and 10 mg Nalbuphine immediately prior to OR to mildly sedate the patient in order to relax the patient and prevent sudden increase in blood pressure secondary to pain during subarachnoid block. Regional anesthesia (spinal or combined spinal-epidural) has been successfully used for cesarean delivery in patients with paraplegia, autonomic hyperreflexia, cervical AVM, and ventriculoperitoneal shunt. [17] In this case, a regional anesthetic technique, more specifically subarachnoid block, was preferred due to the urgency of the situation and ease of administration. It avoids the haemodynamic stress associated with laryngoscopy, intubation and extubation during general anesthesia [18,15] It is also important to avoid hypotension during subarachnoid and epidural block [15] Preloading of 500cc D5LRS was done prior to induction of anesthesia to prevent hypotension and careful monitoring was done to prevent or correct sudden hemodynamic changes that may be detrimental to the patient. Epidural anesthesia can also be considered, but since the patient was already in labor, it could be difficult to insert the epidural catheter. Care must be exercised to ensure true extradural placement of an epidural catheter. Epidural injection can cause an increase in ICP by compression of the dural sac. [19] The potential for a serious cerebral complication after dural puncture is of major concern if the ICP is high, because a rapid decrease in spinal cerebrospinal fluid (CSF) pressure may cause herniation or intracranial hemorrhage. [16] Intracranial subdural hematoma formation after epidural anesthesia and SAH after spinal anesthesia have been reported several times in the literature [20] and are thought to result from acute CSF pressure changes.

General anesthesia is also an alternative anesthetic technique, however, there are haemodynamic stresses associated with laryngoscopy, intubation and extubation which can contribute to the rebleeding of the patients AVM. [18,15]

Principal goals are smooth induction and intubation with tight blood pressure control. As a result of fat deposition and upper airway mucosal edema, pregnant women are more likely to be difficult to intubate.

CONCLUSION

The choice of anesthetic technique for Caesarean section of a pregnant woman with cerebral arteriovenous malformation is made to maintain a stable cardiovascular system and is decided on a case to case basis [15], but due to the rarity of this condition, no definitive guidelines exist. Considering optimal maternal and fetal well being, subarachnoid block can be used satisfactorily for emergency cesarean section with bilateral tubal ligation of a pregnant woman with cerebral arteriovenous malformation.

ANESTHETIC MANAGEMENT OF EMERGENCY CESAREAN SECTION WITH BILATERAL TUBAL LIGATION OF A WOMAN WITH SUBARACHNOID HEMORRHAGE SECONDARY TO RUPTURED ARTERIOVENOUS MALFORMATION, LEFT TEMPORAL LOBE: A CASE REPORT

ANESTHETIC MANAGEMENT OF EMERGENCY CESAREAN SECTION WITH BILATERAL TUBAL LIGATION OF A WOMAN WITH SUBARACHNOID HEMORRHAGE SECONDARY TO RUPTURED ARTERIOVENOUS MALFORMATION, LEFT TEMPORAL LOBE: A CASE REPORT

SUBMITTED TO

ILOCOS TRAINING AND REGIONAL MEDICAL CENTER COMMITTEE ON RESEARCH

SUBMITTED BY

JANILIE Q. SILVESTRE,M.D. DPARTMENT OF ANESTHESIOLOGY ILOCOS TRAINING AND REGIONAL MEDICAL CENTER