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Subdural Hematoma in a Patient with HELLP Syndrome
Abstract Number: SA-60
Abstract Type: Case Report/Case Series
Neuroaxial anesthesia is a common and popular mode of analgesia for pregnant patients. Though safe, epidural and spinal blocks do have rare complications, such as epidural hematoma and intracranial subdural hematoma with an incidence of approximately 0.05% or 1:200,000. We report a case of subdural hematoma in a parturient with HELLP syndrome.
A 19 years old, G1P0, presented to labor and delivery with new onset of labor with a cervical exam of 2.5 cm dilated and 80% effaced. On admission, patient was found have elevated blood pressures and lower extremity edema. PIH labs were sent, showing platelets of 63, with giant platelets observed on slide examination. Magnesium therapy was initiated for seizure prophylaxis. Patient continued to have labile blood pressures and increasing facial edema. A decision was made to proceed with urgent C-Section for severe pre-eclampsia. Pre-operative platelet count of 52,000. Within this clinical setting, the potential for severe airway edema was evident and the decision was made to proceed with C-Section under spinal anesthesia after an infusion of one unit of platelets. Spinal was performed using a 27 gauge Whitacre needle, bupivacaine, fentanyl and morphine. C-section was performed with no anesthetic or surgical complications. Neurochecks were performed every one hour for twenty four hours to evaluate for manifestations of potential epidural hematoma.
The patient’s post-operative course was uneventful until post-op day 2, in which the patient began to complain of a non-positional headache with accompanied blood pressure elevations. On post-op day 3, an MRI of the brain was ordered. Initial MRI showed thin bilateral acute subdural hematomas in the frontotemporal regions, as well as findings of benign intracranial hypotension. Neurosurgical evaluation did not reveal any gross or focal neurological deficits and recommendation was to monitor the neurological function. Repeat MRI on post op day 4 showed no acute worsening of the subdural hematomas and the headache began to resolve. The patient experienced complete resolution of the headache by post-op day 5 and was subsequently discharged.
HELLP syndrome is a variant of severe preeclampsia and parturients develop dysfunctional and low platelet count. Low platelets alone are a risk for atraumatic parenchymal bleeding and subdural hematoma. Understandably, dural puncture in a patient with HELLP syndrome is relatively contraindicated due to the potential risk of epidural hematoma and CSF leak. Prolonged CSF leak results in intracranial hypotension which can lead to caudal traction on the brain, rupture of bridging veins and subsequent subdural hematoma.
Small subdural hematomas can be treated conservatively with fluids, caffeine, analgesia, and a close neurology and MRI follow up to recognize worsening symptoms as early as possible and proceed with surgical decompression for progressive neurological deficits.