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Anesthetic Management of a Parturient with Atypical Eclampsia During a Cesarean Section
Abstract Number: S3D-5
Abstract Type: Case Report/Case Series
Introduction: Preeclampsia, eclampsia, and HELP syndrome are disorders associated with substantial maternal and perinatal morbidity(1). Atypical cases are those that develop at < 20 weeks of gestation and > 48 hours after delivery, also those that have some of the signs and symptoms without the usual hypertension or proteinuria, in rare cases eclampsia could be the sole sign that the patient will present with and no other warning signs or symptoms. Recent data showed that preeclampsia and eclampsia may develop in the absence of hypertension or proteinuria.
Case Report: A previously healthy 35yo caucasian female, G2 P1001, with no significant obstetrical history at term, presented for an elective cesarean section due to placenta previa, her preoperative lab results were within normal limits. Single bolus spinal anesthetic was planned using 1.4 ml of hyperbaric bupivacaine 0.75%; fentanyl 15mcg and preservative free morphine 300 mcg were added to the mixture. After the neuraxial block was performed the patient was placed in supine position with left uterine displacement, standard monitors were applied and the patient was prepared to undergo surgery, fetal heart rate was 146 beats per minute. Moments after the intratechal anesthetic placement the patient complained of having the “worst headache of her life”, and immediately developed a generalized tonic clonic seizure, blood pressure was noted to be 180/126 mmHg, the surgeon was alerted and general anesthesia was rapidly induced with propofol 200 mg and succinylcholine 80 mg, the cesarean section took place and the delivery of the fetus was uncomplicated, APGARS were 9 at 1min and 9 at 5min, cord gases were normal. At the end of the surgery the patient was extubated, immediate physical exam with emphasis in the neurological system was completely normal. In the PACU and after discussion of the event with the OB team, eclamptic seizure was assumed and treatment with MgS04 was started, in the PACU the patient progressively started to show elevated blood pressures and needed pharmacological therapy to control her symptoms, laboratory results continued to be within normal limits, the only abnormality was progressive elevation in the uric acid value.
MRI examination of the brain showed “findings suggestive of eclampsia or PRES”.
Discussion: Eclmapsia could present with no associated signs, symptoms or lab abnormalities, approximately 30% of women with eclampsia will never present edema; in the case of a seizure in a previously healthy pregnant patient, eclampsia should be assumed and a management plan should take place immediately and avoid consuming time searching for a rare disease in a differential diagnosis, it is important to make timely and accurate diagnoses to avoid adverse outcomes. MgSO4 infusion should be started early and anihypertensive medication should be considered.
Baha M Sibai, et al. AJOG. May 2009;200 (5):481.e1–481.e7