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Early onset preeclampsia at 23 weeks in a teenager with a history of traumatic brain injury, drug use and scoliosis: a post-cesarean debacle
Abstract Number: RF6AI-248
Abstract Type: Case Report Case Series
Early onset preeclampsia (EOP) poses challenges with regards to timing of delivery. We describe here the management of an urgent cesarean delivery (CD) for EOP with severe features in a developmentally delayed teenager.
A 16-yo G1P0 diagnosed at 23-24 weeks with EOP was advised to terminate the pregnancy due to the combination of traumatic brain injury at age 10 with developmental delay, drug use during pregnancy, and foster care with minimal care by her 33-yo mother, but she had refused. She was now admitted at 28 weeks “feeling weak”, BP 147/103mmHg and massive anasarca in the setting of HELLP and positive amphetamine urine drug screen. Abdominal US showed bilateral pleural effusions, ascites, cholelithiasis with gallbladder edema and wall thickening. IV labetalol and MgSO4 were started. Obstetrics, anesthesia, psychiatry, social work and legal were convened to discuss appropriate steps for urgent CD in the setting of HELLP. Consent for neuraxial anesthesia (CSE) with possible GA was obtained after discussing with her and legal guardian via FaceTime (grandmother), although she was ‘afraid of a spinal because of scoliosis’.
In the OR, she became uncooperative, and in lieu of CSE, single shot spinal (hyperbaric bupivacaine 12mg, fentanyl 15mcg, morphine 300mcg, clonidine 40mcg) was swiftly done while giving 2mg midazolam. CD was started with patient awake, 4 liters of ascites were removed upon entering peritoneum, delivery was simple (baby girl 1280g, Apgar 2/8/9). Oxytocin infusion was started and 1g TXA given. Blood loss was 700ml; 3L of lactated ringers, 500ml 5% albumin and phenylephrine ensured stable hemodynamics (Fig).
Postpartum recovery was initially uneventful, pain was well controlled with minimal oral medication. On day 3, TTE to evaluate persistent tachycardia showed a large pericardial effusion, right atrial diastolic invagination and right ventricle compression, which was drained (520ml serous fluid) and colchicine was started. On day 5, Tamiflu was started for a positive Influenza test. On day 10, persistent leukocytosis was attributed to a rectus sheath abscess, and drainage was performed under GA. With resolution of acute kidney injury and antibiotic completion, she was medically cleared for discharge on day 14.
Neuraxial anesthesia for CD proved to be optimal in the context of EOP with anasarca, but the PP course was an unusual trifecta of pericardial effusion, the flu and abdominal abscess.