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

Not All Swelling is Edema in Eclampsia: A Rare and Life-threatening Potential Complication of Eclamptic Seizures

Abstract Number: 83
Abstract Type: Case Report/Case Series

Brian W Paitsel M.D.1 ; Newell Daly D.O.2; Hale Aksu M.D.3; Terrence Bogard M.D.4; Peter Pan M.S.E.E., M.D.5

Introduction

Subcutaneous emphysema (SE) with pneumomediastinum (PM) or pneumothoraces (PT) is a rare but potentially lethal complication of 2nd stage labor. This condition was first referenced in 1618 when Louise Bourgeois, midwife to French Queen, wrote, "I saw that she tried to stop crying out and I implored her not to stop for fear that her neck might swell." and subsequently described in 1945 as Hammans syndrome, likely due to high intrathoracic pressure from repeated Valsalva maneuvers during labor.1,2 To our knowledge, this syndrome has not been reported in eclamptics or parturients without active labor. We report a first case of SE and PT presenting as facial-cervical swelling in an eclamptic undergoing C/S without active labor.

Case Report

A 24 y/o, 65 kg, 152 cm primagravida with severe pre-eclampsia & a history of asthma was admitted at 38 weeks' gestation for Mg administration and oxytocin induction. The patient developed a tonic-clonic seizure but stabilized quickly except with worsening generalized and facial edema. Recurrent FHR decelerations lead to an urgent C/S. Despite a bilateral T4 anesthetic level achieved via a previously placed epidural, the patient was combatively uncooperative & a RSI was successful and atraumatic. Surgery was completed without complication. Upon emergence, the patient was hemodynamically stable with spontaneous respiration, but she did not respond purposefully & had increased facial edema. She remained intubated & experienced a 1-min tonic-clonic eclamptic seizure. Upon further examination, crepitus was noted on the neck, face and chest with bilateral decreased breath sounds. A CXR revealed bilateral PT for which chest tubes were placed. She was extubated the next day & discharged on POD 4 without sequelae.

Discussion

SE with or without PM or PT is a rare but potentially life-threatening complication of active 2nd-stage labor with an estimated incidence as low as 1:100,0003. In this first case of an eclamptic undergoing C/S without active labor, the likely mechanism was due to increased intra-alveolar pressure generated by expiratory effort against a closed glottis during seizure leading to the rupture of marginally situated alveoli into the perivascular tissue planes. The presence of airspace disease may have predisposed our patient to this complication. Our presumption of the facial-cervical swelling to be edema of eclampsia illustrates the importance of avoiding preconceived bias in making a diagnosis and more closely examining patients after eclamptic seizures. If we had recognized the crepitus earlier, we might have avoided general anesthesia, positive pressure ventilation, and nitrous oxide. In conclusion, this first case report of SE with PT in association with eclamptic seizures and general anesthesia without active labor reminds us of this life-threatening potential pulmonary complication of eclamptic seizures & the importance of closer examination in all patients after eclamptic seiz

SOAP 2009