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Anesthetic Management of a Parturient with Malaria
Abstract Number: 267
Abstract Type: Case Report/Case Series
Case Report: A 22 year old Nigerian immigrant G1P0, at 30 weeks gestation presented with 3 days of fever and chills following her return from a visit to Africa. PMH significant for 2 episodes of malaria, most recently five years prior to admission. Hgb was 8.9, hct 27, platelet count 72,000. Peripheral blood smear revealed malarial trophozoites. Treatment was started with chloroquine, iron and folic acid. By day 3 intermittent fevers continued, platelets dropped to 31,000. Despite 2 units transfused PRBCs, the hgb and hct were 9.9 and 29.9. Due to the lack of response and possibility of drug-induced thrombocytopenia, chloroquine was replaced by quinine and clindamycin; erythropoetin was started. On day 4 BP increased to 142/92, platelets dropped to 20,000. IV immunoglobulin was administered. On day 5 BP increased to 174/118; magnesium sulfate and labetolol were started for pregnancy-induced HTN. The decision was made to deliver by cesarean section. Preop hgb 9.0, platelets 41,000; she received 2 units PRBCs, 10 units of platelets. Prior to induction of GA, IV nitroglycerin was titrated to control the BP. After preoxygenation the patient underwent rapid sequence induction with thiopental 5mg/kg, succinylcholine 1mg/Kg, isoflurane .75 MAC for maintenance. A live male infant was delivered 3 minutes after skin incision, wt. 1620 gm, apgars 4/6, requiring ventilatory assistance. After delivery anesthesia was maintained with N2O, fentanyl, midazolam and low dose isoflurane. Blood loss was 1200 ml, 1 unit PRBCs transfused. The patient was extubated and started on IVPCA morphine. Postoperatively, hypertension persisted requiring the addition of enalapril. Thrombocytopenia continued (22,000 on POD5), anemia persisted, LDH increased to 1600, renal indices worsened. Peripheral smear consistent with thrombotic thrombocytopenic purpura. She required multiple treatments with plasmapheresis before platelet count normalized. Discharged home on POD15.
Discussion: Pregnancy and malaria are mutually exacerbating conditions. The malarial parasite accumulates and develops in the placenta, interfering with fetal oxygenation and nutrition. Increased parasitemia in pregnancy results in more severe malarial complications. Challenges faced by the anesthesiologist may include CNS changes due to cerebral malaria, non-cardiogenic pulmonary edema with increased capillary permeability, anemia, thrombocytopenia, hypoglycemia, metabolic acidosis, renal dysfunction, jaundice and abnormal liver function. There is some evidence that preeclampsia is more common in malaria. Both conditions result in reduced placental perfusion, loss of placental integrity and endothelial cell dysfunction. Preeclampsia may aggravate many malarial complications. Symptoms common to both diseases may make differential diagnosis and proper treatment difficult. In addition, the anesthesiologist must be familiar with side effects of anti-malarial agents, such as drug-induced anemia and thrombocytopenia.