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Expedited Diagnosis of Preeclampsia Secondary to Emergency Airway Findings
Abstract Number: SAT-79
Abstract Type: Case Report/Case Series
Preeclampsia is characterized by multi-organ damage and hypoperfusion resulting from a complex interplay of genetic and environmental factors resulting in glomerular endotheliosis and generalized inflammation increasing vascular permeability.1 Apart from changes in coagulopathy and hemodynamics, anesthetic providers must also be aware of profound alterations in the upper airway of parturients and the resultant implications on securing an airway.2 While obstetricians follow patients throughout pregnancy and are often the first to recognize preeclampsia, anesthesiologists have unique insights that may aid in expedited diagnosis.
Our patient is a 31YO G2P0 healthy parturient at 38 weeks gestation who presented for cesarean delivery from the office due to breech presentation in the setting of spontaneous rupture of membranes. During IV placement, she had a vasovagal episode with resultant fetal decelerations prompting rapid intervention. A single dose of 10mg of ephedrine was given for hypotension with resultant sustained hypertension with systolic blood pressures greater than 150mmHg. Despite initial improvement, the fetal heart rate tracing again deteriorated necessitating emergent delivery.
General anesthesia was induced, however multiple attempts at endotracheal intubation with various airway adjuncts were unsuccessful secondary to marked airway edema despite adequate view with a video laryngoscope. A laryngeal mask airway (LMA) was seated and ventilation was confirmed, at which time surgery was initiated. A subsequent attempt to secure an endotracheal tube via a fiberoptic scope through the LMA again revealed extremely edematous vocal cords and larynx. The case was completed shortly thereafter with ventilation via the LMA. The patient suffered no adverse outcome. The airway edema and sustained hypertension incited the anesthesia team to expedite a work up for preeclampsia demonstrating a protein to creatinine ratio of 3.8 and thus confirming a diagnosis of preeclampsia with severe features. Magnesium sulfate therapy was then initiated.
The above case highlights the duty of all medical providers to be attentive to the possible presentations of preeclampsia as this disease process can significantly affect both the parturient and the fetus. In this instance it was gross edema, notably in the upper airway that demonstrated pathological vascular permeability. This case also highlights the importance of the difficult airway algorithm in emergency situations, especially in a pregnant patient, as the rate of failed intubation is much more common. Heightened caution and early activation of resources resulted in delivering a healthy newborn to a healthy mother.
1Hladunewich et al. Pathophysiology of the clinical manifestations of preeclampsia. Clin J Am Soc Nephrol. 2007 May;2(3);543-9.
2 Izci et al. The upper airway in pregnancy and pre-eclampsia. Am J Respir Crit Care Med. 2003 Jan 15;167(2):137-40.