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Anesthetic Management in Cesarean Hysterectomy for a Parturient with Morbidly Adherent Placenta and Intracranial Aneurysm
Abstract Number: RF6AI-380
Abstract Type: Case Report Case Series
A 37 year old, G9P6 at 36 weeks gestation presented for a scheduled Cesarean hysterectomy for suspected morbidly adherent placenta (increata/percreta). She had a complex medical history including recurrent and unruptured cerebral aneurysms, known ruptured cerebral aneurysms with subarachnoid hemorrhage, severe asthma/COPD overlap syndrome (ACOS), chronic hypertension, seizures, and mood disorder. Preoperative workup included a multidisciplinary approach with neurosurgical and pulmonary consultations. Patient’s airway was carefully assessed. Pre-induction arterial and central venous catheters were placed and general endotracheal anesthesia was performed with a rapid sequence induction. The patient was maintained with sevoflurane with remifentanil infusions, kept normotensive and hemodynamically stable intraoperatively using a phenylephrine infusion and other vasoactive medications. The patient required one unit of packed red blood cells. A male infant was delivered and did well postoperatively. The patient had an uneventful surgical ICU stay postoperatively. She was discharged on postpartum day 5.
The prevalence of cerebral aneurysms in the general population in the United States is estimated to be 4% to 6%, and the incidence is increased during late gestation(1). SAH has a somber prognosis during pregnancy, and predisposing factors for rupture include pregnancy, a history of previous rupture, and an elevated transmural pressure gradient(1). The transmural pressure gradient is influenced by the difference between the pressure inside the aneurysm (mean arterial pressure [MAP]) and the pressure outside the aneurysm (intracranial pressure [ICP]). Thus, sudden increases in MAP and/or reduction in ICP elevates transmural pressure, which may lead to aneurysmal rupture.
Neuraxial anesthesia has been successfully described for parturients with unruptured intracranial aneurysms(2), but our parturient had a concurrent morbidly adherent placenta. We decided on performing general anesthesia given the potential for major blood loss, concern for inability of the patient to tolerate being awake during surgery, and the risk for dural puncture potentially causing aneurysmal rupture which has been described previously in literature. A remifentanil infusion was chosen to lessen volatile anesthetic requirement to avoid cerebral vasodilation and subsequent increase in ICP.
We conclude that pregnancy with intracranial aneurysms and morbidly adherent placenta is a rare and complex clinical situation, and management of these patients requires a multidisciplinary team approach. This patient had a stable peripartum course and delivered a healthy infant despite many potential problems.
1. Murray MJ, Rose SH, Wedel DJ et al. Faust's Anesthesiology Review. Churchill Livingstone; 2013.
2. Carvalho Lde S, Vilas boas WW. Anesthetic conduct in cesarean section in a parturient with unruptured intracranial aneurysm. Rev Bras Anestesiol. 2009;59(6):746-50.