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Spinal anesthesia for cesarean delivery in a morbidly obese women with recent subarachnoid hemorrhage in the setting of early onset preeclampsia
Abstract Number: FCD-247
Abstract Type: Original Research
Intracranial hemorrhage (ICH) in pregnancy is a rare but devastating event (7:100,000 deliveries) causing up to 12% of maternal deaths. Spontaneous subarachnoid hemorrhage (SAH) is more commonly associated with pre-existing aneurysms and neurovascular malformations,1 while spontaneous intracerebral hemorrhage (ICH) in obstetric patients is most often associated with hypertensive disorders.2 We present here the management of a women with SHA complicating early onset preeclampsia (EOP).
A morbidly obese (BMI 48) 33-yo G2P0 at 28 weeks with persistent right temporal headache, generalized neck pain and rigidity, new onset high BP (160/80mmHg) was diagnosed with EOP with severe features; MgSO4, nifedipine/labetalol, and betamethasone were started. Cerebral MRI was requested which confirmed suspicion of SHA (Figure). Decision was to proceed with cesarean delivery with spinal anesthesia (increased ICP was deemed unlikely by neurologists based on presentation and imaging). With an arterial line for BP monitoring, spinal anesthesia (27G Whitacre) was provided with bupivacaine 0.75% 12mg, fentanyl 15 mcg, morphine 150 mcg. Other than heme-stained CSF (photo), spinal was unremarkable, with patient alert and oriented before and throughout delivery of a 1310g baby. Patient remained in the hospital until POD7 for neurological monitoring given high risk for recurrent intracranial bleed and/or vasospasm. BP was managed (goal SBP<140mmHg) on labetalol/nimodipine/verapamil. Daily transcranial doppler monitoring and repeat MRA were stable overall, and patient remained neurologically intact at time of discharge.
There is little data to guide treatment of EOP complicated by ICH, but management remains control of hypertension, seizure prophylaxis, and expedited delivery. The deleterious effects of blood in the cranial vault only accentuates these issues. In the case of our patient, prompt treatment with labetalol, nifedipine, and MgSO4 appeared effective. The absence of mass effect and obstructive hydrocephalus has been shown to correlate with absent-to-minimal risk of herniation from dural puncture, in which case it is reasonable to proceed with neuraxial technique.3 In summary, we performed a spinal anesthetic in women with acute SAH in the setting of EOP in a morbidly obese women, with a spontaneous recovery and resolution of all predelivery symptoms.
1. Neurology. 2006;67:424–9.
2. Obstet Med. 2009;2:142-8.
3. Anesthesiology 2013;119:703-18