///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Elective Intubation in Parturient with Severe HELLP

Abstract Number: 172
Abstract Type: Case Report/Case Series

Joanna A Kountanis M.D.1 ; Monica Servin M.D.2; Jill Mhyre M.D.3

Introduction: Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome may lead to serious sequelae, including disseminated intravascular coagulation, acute renal failure, pulmonary edema, hemorrhage, and maternal death.(1) We present a case of pre-emptive airway management, undertaken in the presence of fulminant HELLP syndrome.

Case Report: A 36-year-old G1P0 at 28 weeks gestation with body mass index 51 kg/m2 presented to an outside hospital with fetal demise, profuse vaginal bleeding, anemia, and severe preeclampsia. Within 12 hours of admission she developed HELLP syndrome and acute renal failure, and was transferred to our medical intensive care unit. Hypertension control (maximum 250/121) and seizure prophylaxis were provided by labetalol, nitroprusside, and magnesium infusions. Oxygen saturations were maintained at 98% on 3L nasal cannula. Chest radiograph showed mild pulmonary edema and hypoinflation. Significant lab results included Hct 24, Plts 18, Cr 5.0, K 6.3, Na 132, D-dimer 51.5. Physical exam revealed an edematous oropharynx, Mallampati 3, short obese neck, and pitting edema in the lower extremities. The obstetric team planned induction and vaginal delivery. The anesthetic plan included an elective awake fiberoptic intubation (AFOI), given the potential for massive obstetric hemorrhage, airway edema, and pulmonary edema in a coagulopathic patient with an anticipated difficult airway. This was accomplished in the operating room with topical local anesthesia and a remifentanil infusion.(2) A 7 French peripheral venous catheter was also inserted. After successful AFOI, induction, and delivery of a stillborn fetus, she hemorrhaged (EBL 2000cc), requiring transfusion of 5 PRBCs, 2 five pack platelets, and 1 FFP. As the patient was already intubated, immediate deepening of her sedation was possible in order to facilitate bedside manual placental extraction, Bakiri balloon placement, and rapid control of blood loss. The patient was extubated over a Cook catheter 4 days postpartum after airway edema and coagulopathy improved.

Discussion: This case illustrates the importance of well-coordinated multidisciplinary care for a morbidly obese patient with fulminant HELLP syndrome and anticipated difficult airway. Given the patients coagulopathy and gestational age, vaginal delivery was deemed safer than cesarean hysterotomy. However, the progress of labor could not be anticipated given the patients obesity and the macerated state of the fetus. Furthermore, HELLP syndrome and renal failure threatened to exacerbate her coagulopathy, pulmonary edema, and airway edema. Therefore, preemptive AFOI with sedation and mechanical ventilation allowed for a gradual induction of labor, followed by rapid obstetric intervention and resuscitation at the time of delivery and post-partum hemorrhage.

(1) Am J Obstet Gynecol 1993;169(4):1000-6

(2) Anesth Analg 2008;106(5 Suppl):A28. www.soap.org/pdfs/ANE_New_SOAP_May_Abstracts_2008.pdf

SOAP 2009