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Bedside Cesarean Section in Trauma Bay: A Lesson on Emergency Management and Hypertensive Crisis
Abstract Number: RF2BB-61
Abstract Type: Case Report Case Series
Background: Obstetric emergencies can present suddenly. Hypertension complicates 5-10% of pregnancies in the United States and along with cardiovascular conditions, is amongst the top causes of pregnancy related deaths [1, 2]. Hypertensive emergency during pregnancy can cause complications necessitating urgent evaluation and intervention.
Case report: A 33 year old G1 at 36 weeks with a PMH of chronic hypertension and acute methamphetamine use presented to the Emergency Department (ED) as a transfer from an outside hospital for superimposed preeclampsia. During transfer she developed worsening hypoxic respiratory failure with confusion and hemoptysis. Upon arrival her BP was 198/126, HR 118, RR 28 and SpO2 40%. She was placed on non-rebreather with improvement to 78%. She was intubated by the ED physician using midazolam and succinylcholine with improved SpO2 90%. Upon arrival of the Labor and Delivery team, the FHR was in the 80-90s and the decision was made to perform an emergent bedside cesarean section for terminal deceleration and risk of decompensation during transfer to the OR. Anesthesia was managed with a propofol infusion and rocuronium. Monitoring included an arterial line and she received a nicardipine infusion with BP improvement to the 160s/80s. The fetus was delivered after 6 minutes with Apgars of 2 and 7 at 1 and 5 minutes. The infant taken to NICU on NCPAP and weaned to room air over 12 hours. Patient’s ABG with FiO2 of 100% was pH 7.07, pCO2 47, pO2 76, HCO3 13, BE -16 and lactic acid 4.4. She was given 1 ampule of bicarbonate. Post-op CT chest showed diffuse alveolar hemorrhage and pulmonary edema. CT head showed a small hypodensity in the left occipital lobe. She was transferred to the ICU with SpO2 90% and placed on APRV mode with SpO2 improvement to the upper 90s. Bedside TTE was done showing LVH with left atrial dilation. IV Lasix was added. She was extubated on postpartum day 1, transitioned from nicardipine infusion to nifedipine and discharged on postpartum day 4.
Discussion: The patient likely experienced acute LV dysfunction secondary to hypertensive emergency due to acute methamphetamine use, however superimposed preeclampsia with severe features, pulmonary embolism and CVA were considered. The decision to perform bedside cesarean delivery versus in the OR is a debated topic and choice of location varies depending on the hospital layout and patient situation. Benefits of delivery in the OR include sterile conditions, familiar surroundings, access to necessary equipment and personnel including Neonatologists while the benefit of performing a bedside delivery includes faster time to delivery .
1. Too et al. Semin Perinatol. 2013; 37(4):280-287.
2. Creanga et al. Obstet Gynecol. 2017;130(2):366-373.
3. Lipman et al. Obstetric Anesthesia Digest. 2012; 32(4):226.