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Anesthetic Management of a Parturient with Severe Preeclampsia and Diabetic Ketoacidosis for Emergent Cesarean Section
Abstract Number: F-75
Abstract Type: Case Report/Case Series
A 40 year old Female, G4P3, at 38 weeks with unknown PMH presented emergently to the labor and delivery floor with complaints of abdominal pain, nausea/vomiting, and headaches. The patient had no prenatal care prior to arrival at the hospital. Upon arrival to the triage bay, a category 3 tracing was noted on fetal monitors. The patient’s blood pressures were measured greater than 160/90, and the patient endorsed severe headaches for the past several weeks, indicating a high suspicion for severe preeclampsia. In addition a finger stick was performed with glucose greater than 600, and ketones were noted on urine dipstick, consistent with a diagnosis of Diabetic Ketoacidosis (DKA). The patient was obese and had an unfavorable airway examination, and had eaten a full meal within the last hour.
The decision was made to proceed to the operating room for emergent cesarean section. No laboratory data was available at the time of emergent transfer to the operating room. With a high suspicion for preeclampsia with severe features, an unfavorable airway exam and high risk of aspiration given the recent meal, a calculated decision was made to perform the cesarean section under neuraxial anesthesia. Spinal anesthesia was induced uneventfully and the patient developed a T4 level bilaterally. Two large bore peripheral IVs and arterial line was placed prior to skin incision. ABG prior to incision showed a pH of 7.20, paCO2 of 15, HCO3- of 9, lactate of 2.5, glucose of 600. In addition, the patient was noted to be markedly hyponatremic with a Na 128, as well as profoundly anemic with a starting Hct of 21%. Creatinine was also elevated at 1.2mg/dl, indicating signs of renal dysfunction.
The baby was delivered uneventfully, with APGARs of 6/8, and an initial finger stick glucose greater than 500mg/dl. Good uterine tone and hemostasis was achieved post-delivery.
Serial ABGs were performed throughout the cesarean section and the DKA was managed with an initial insulin bolus followed by an insulin infusion. The patient was hydrated with isotonic balanced salt saline. Electrolytes, including potassium were repleted intraoperatively. The patient was transferred to the medical ICU for further management post operatively.
This case highlights a successful anesthetic management of a parturient with severe preeclampsia and concomitant DKA undergoing an emergent cesarean section. Both preeclampsia and DKA are associated with a significant maternal and fetal mortality. DKA is associated with multiple metabolic and electrolyte abnormalities which need to be judiciously treated and monitored. When combined with severe preeclampsia, anesthetic and intraoperative management becomes even more complex. Our case demonstrates key management points for both disorders.