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Anesthetic Management of a Parturient with Subarachnoid Hemorrhage
Abstract Number: T3D-10
Abstract Type: Case Report/Case Series
Intro: Subarachnoid hemorrhage (SAH) is a rare (5.8-17.1 per 100,000 deliveries) but significant cause of maternal morbidity and mortality. We present a case of peripartum SAH complicated by preeclampsia necessitating delivery.
Case: This is a 31 y.o. G4P0121 African American female at 32 weeks and 2 days gestational age, with a history of preeclampsia in a prior pregnancy, initially presenting to an outside hospital after developing a sudden onset, severe headache. She was found to be hypertensive (SBP 180-190 mmHg), lethargic, and only responsive to painful stimuli warranting intubation. A head CT demonstrated diffuse SAH (HH3/F4), concerning for posterior circulation aneurysm, with edema but no midline shift or cerebellar tonsillar herniation. Laboratory values were unremarkable (AST/ALT 18/11, Cr 0.73, and platelets 265,000). Due to concern for preeclampsia in a preterm pregnancy, magnesium sulfate and betamethasone were administered and the patient was transferred to our tertiary care center. On arrival, obstetrics and neurosurgery were consulted. Given the stable fetal status, the decision was made to proceed with a cerebral angiogram with possible embolization. Initial angiogram and subsequent MRI brain/cervical spine were negative for aneurysm or apparent source of hemorrhage. On post-bleed day 2, the patient neurologically improved and was extubated. At that time, laboratory values revealed a UP:C 0.527 and 24-hour urine protein of 692 mg. Expectant management of pre-eclampsia ensued with a plan for cesarean delivery (CD), to limit valsalva, at 34 weeks gestation. However, on post-bleed day 4, the patient developed severe range blood pressures and worsening headache necessitating CD under general anesthesia. Delivery of a live born male with APGARS 6 and 9 occurred otherwise uneventfully. Two repeat angiograms were negative for aneurysm, malformation, or source of hemorrhage at 1 and 3 weeks post-SAH.
Discussion: The etiology of peripartum SAH is varied. In pregnancy, aneurysms are a less common cause of SAH compared to the general population. There is also an association between hypertensive disorders in pregnancy and peripartum SAH. Our patient had multiple risk factors for preeclampsia. In this case, the overlap of symptoms observed in SAH (including hypertension and headache) and preeclampsia complicated obstetric and anesthetic clinical decision making. As the mode of delivery was CD, neuraxial and general anesthesia were considered. Despite a lack of significant edema, midline shift, or hydrocephalus on imaging, her acute symptoms of headache and elevated blood pressure could represent elevated ICP. Therefore, CD was performed under general anesthesia with neuroprotective precautions.
1. Leffert et al. Anesthesiology 2013;119:703-18.
2. Bateman et al. Anesthesiology 2012;116:324-33.