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Craniotomy for meningioma resection in a parturient at 28 weeks gestation complicated by intraoperative late decelerations
Abstract Number: F-62
Abstract Type: Case Report/Case Series
A 31 year old G1P0 at 28 weeks gestation with no past medical history presented with 3 weeks of worsening visual acuity bilaterally. Magnetic resonance imaging showed a 4.5 x 4.0 x 2.5 cm mass in the tuberculum sella compressing the optic chiasm and a second mass 2.3 x 1.7 x 1 cm in the right temporal lobe. Both masses were consistent with meningiomas. Multidisciplinary management was coordinated among obstetrics, obstetric anesthesiology, and neurosurgery. The patient was scheduled for a craniotomy to resect both masses.
Continuous intraoperative fetal monitoring was done by an obstetric nurse. A cesarean delivery tray was available in the operating room in case a poor fetal tracing necessitated an emergency delivery. Rapid sequence induction was performed, 3 large-bore peripheral intravenous catheters and a radial arterial line were placed. Maintenance of anesthesia consisted of 1/2 minimum alveolar concentration of sevoflurane and a propofol infusion. A remifentanil infusion was added for analgesia at incision and discontinued once the dura was opened. In order to promote brain relaxation, 0.5 g/kg of mannitol was infused and the patient was hyperventilated to an end tidal CO2 between 28 and 30 mmHg. After 8 hours, the fetal heart tracing showed frequent late decelerations. In consultation with the maternal fetal medicine service, terbutaline was administered, followed by subsequent resolution of the late decelerations. Six hours later, the surgery was completed without further complications and the patient was extubated and transferred to the intensive care unit in stable condition.
Limited information is available regarding neurological surgery in obstetric patients. Considerations for intraoperative care include the degree of hyperventilation and the use of mannitol. Although limited information is available regarding the effects of mannitol administration during pregnancy, fetal hyperosmolarity and reduced fetal lung fluid production can occur (1). Initial actions for a nonreassuring fetal heart tracing include optimization of maternal blood pressure, oxygenation, and acid-base status, as well as informing the surgical and obstetrical teams. In our case, terbutaline was administered for tocolysis and an obstetrical team was immediately available for a cesarean delivery. Multidisciplinary planning is essential for optimal care during nonobstetric surgery.