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Low Dose Combined Spinal Epidural in Preterm Parturient Requiring Urgent Cesarean Delivery with Severe Preeclampsia, Pulmonary Edema, and Chronic Kidney Disease
Abstract Number: RF1BA-433
Abstract Type: Case Report Case Series
Introduction: Preeclampsia affects 3-5% of all pregnancies, contributes to 15% of preterm deliveries, and remains a leading cause of maternal morbidity and mortality. In addition, parturients with diabetic nephropathy are at higher risk for preterm delivery and preeclampsia. Patients who present with early onset preeclampsia may manifest with more severe symptomatology that necessitates a higher level of anesthetic planning for delivery. Exaggerated physiologic response to full dose spinal technique for cesarean delivery (CD) may be poorly tolerated in this cohort. Therefore, an alternative technique such as low dose combined spinal epidural (CSE) may be useful. We report the successful use of low dose CSE to facilitate a urgent cesarean delivery in a young primiparous parturient who presented with preeclampsia with severe features, pulmonary edema, and acute on chronic kidney injury.
Case: Patient is a 24yo G1P0 admitted at 24w gestation who presented with PMH type 1 diabetes in acute DKA with worsening creatinine function, CKD stage 3, cHTN, and asthma. Fetal complications included polyhydramnios and absent umbilical arterial end diastolic flows on Dopplers. Three days later, despite medical management of her chronic systemic disease, she developed acute abdominal pain and dyspnea, escalating her diagnosis to preeclampsia with severe features. A beside transthoracic echocardiogram confirmed a diagnosis of pulmonary edema. Given worsening maternal pulmonary status, the decision was made to proceed with urgent CD. Anesthetic goals included adequate onset of anesthesia and avoidance of a rapid sympathectomy. A reduced dose of 7.5 mg of hyperbaric bupivacaine was injected intrathecally as part of a CSE. Additional epidural fentanyl was administered to attenuate the visceral pain associated with uterine manipulation, and the patient reported adequate analgesia during CD.
This case illustrates the challenges in facilitating an urgent CD in a parturient with early onset preeclampsia with severe features in the second trimester. Point of care ultrasound reaffirmed the importance of avoiding excessive fluid administration which would traditionally be given to treat hypotension after full dose spinal for CD. The urgent preterm delivery in the setting of severe preeclampsia required rapid onset of neuraxial anesthesia. The sympathectomy associated with a traditional spinal dose, typically treated with intravenous fluids, would be deleterious in a patient with pulmonary edema. A low dose CSE (7.5-9 mg hyperbaric bupivacaine) is a technique that has been used in parturients in whom avoidance of hemodynamic perturbation is desirable.
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Jensen D, et al. Diabetes Care. 2010 Jan;33(1): 90-94.