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Delivery time and anesthestic planning for a term parturient with Acute Intracranial Hemorrhage (ICH) Undergoing Urgent Cesarean Delivery
Abstract Number: RF6BI-367
Abstract Type: Case Report Case Series
Introduction: Acute hemorrhagic stroke during pregnancy may lead to significant morbidity or mortality for both mother and fetus. One reason may be lack of clear guidelines for the timing of obstetric treatments/delivery relative to neurosurgical intervention and anesthetic management options. Multidisciplinary planning must consider the status of the mother including radiation exposure, degree of neurological impairment and symptoms as well as fetal status and well-being. In an acute hemorrhagic stroke that requires delivery prior to neurosurgical intervention, anesthesia providers must weigh the risk of neuraxial techniques with risk of general anesthesia. We present a case of successful use of a dural puncture epidural (DPE) technique for a term parturient with acute ICH requiring urgent cesarean delivery (CD).
Case: 37 yo Spanish speaking G4P3 at 39 weeks presented with an acute ICH, mild altered mental status and word finding difficulty. No extremity weakness or focal neurological deficits noted. Imaging was significant for left inferior posterior temporal lobe hemorrhage with no evidence of midline shift. Past obstetric history of two SVDs and unknown CD scar. After initial plan for cerebral angiogram, patient was noted to have contractions and an interdisciplinary meeting concluded to undergo urgent CD prior to neurosurgical intervention.
Intraop: DPE was utilized (lidocaine test dose, 75 mcg fentanyl, 2-chloroprocaine 3% in slow divided doses) for anesthesia. Right radial arterial line was placed prior to DPE dosing. Following fetal delivery, furosemide and esmolol were administered to minimize the increased cardiac output anticipated from autotransfusion. No new neurologic deficits noted during delivery and patient remained hemodynamically stable.
Postop: POD #1, pt underwent diagnostic cerebral angiogram with embolization of a pseudoaneurysm within L temporal AVM and required a complete pseudoaneurysm resection. Following resection, the patient neurologically returned to baseline.
Discussion: Caring for parturients with acute ICH poses unique challenges for the anesthesiologist regarding timing of delivery relative to neurosurgical and obstetric procedures. With an unsecured acute intracranial hemorrhage, anesthesia providers should devise plans to minimize perturbations in cerebral perfusion by preventing abrupt hypotension or hypertension. The degree of neurologic symptoms and the status of the fetus may influence anesthetic technique. We used a neuraxial technique given that the hemorrhage was stable, no deterioration of neurologic symptoms or significant mass effect. Intraoperatively, we avoided hemodynamic changes with slow titration of medications and diuresis following fetal delivery. Utilizing a DPE technique allowed us to control hemodynamics while assessing the patient’s mental status and ultimately resulted in a good outcome for patient and fetus.
Reference: Leffert, L., Schwamm.L. (2013) Anesthesiology 119(3): 703-718