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Cocaine use and Cerebral Aneurysm in the Parturient
Abstract Number: S5C-2
Abstract Type: Case Report/Case Series
Drug use during pregnancy can complicate both maternal and fetal outcomes. Acute intoxication in the setting of other comorbidities can be particularly challenging for providers. Both intracranial pathology and preeclampsia with SF in the setting of acute intoxication will influence the choice of surgical anesthetic and hemodynamic goals in the parturient.
41 y/o, G5P3013, at 25+1 WGA with PMHx of polysubstance abuse, HTN, asthma, cerebral aneurysm, and schizophrenia with BMI 52 presented after a fall. BP was elevated requiring multi-drug anti-HTN therapy. MRI demonstrated known saccular R MCA aneurysm (3.6mm) and new L paraclinoid ICA (3.3 mm) aneurysm; lumbar puncture performed without xanthochromia or elevated opening pressure. Neurosurgery recommended against future vaginal delivery due to possible ICP elevation with labor.
At 39+1 WGA presented with SROM and BP of 182/112 w/o neurologic symptoms. She reported daily cocaine and heroin use, last use 10 hours prior. Pre-E with SF based on BP and elevated Creat (3.49). Mg++ therapy initiated and BP treated with IV Labetalol and Hydralazine.
Decision was made to proceed with CD. Nicardipine gtt initiated and BP titrated to effect with a-line monitoring. CSE placed and pt remained hemodynamically stable with EBL 700. Underwent successful R-sided aneurysm clipping 8 days after delivery and discharged two days later.
While management of the pre-eclamptic is common for the OB anesthesiologist, concomitant cocaine use and intracranial pathology makes management more complicated. Cocaine causes tachycardia and hypertension while increasing risk of malignant arrhythmia or cardiac ischemia. Hypertension was managed intraoperatively with nicardipine, a medication that can be used safely in cocaine intoxication. There is a lack of consensus regarding the safety of Labetalol in the setting of acute cocaine use. A prolonged duration of succinylcholine can be seen in a cocaine-intoxicated patient due to competition for pseudocholinesterase.
Intracranial pathology in the parturient should initiate multidisciplinary discussions to reduce risk of potentially devastating neurologic outcomes. The decision to proceed with either neuraxial or general anesthesia must be carefully considered. Epidural anesthesia may increase ICP due to increased dural compression while spinal anesthesia can lower spinal CSF pressure via volume loss, increasing herniation risk in the at-risk patient. It is essential to control blood pressure and ICP in order to prevent aneurysm rupture. Increased ICP from Valsalva maneuvers during vaginal delivery or uncontrolled HTN may result in aneurysm rupture and intracranial hemorrhage while general anesthesia may result in deleterious elevations in BP during laryngoscopy. In this case neuraxial anesthesia was utilized safely.
Kuczkowski K. Canadian Journal of Anesthesia. 2004; 51(2): 145-154
Leffert L & Schwamm L. Anesthesiology. 2013; 119(3): 703-718