|Year : 2017 | Volume
| Issue : 2 | Page : 109-111
Peri-operative management of severe pre-eclampsia with kyphoscoliosis and poliomyelitis for emergency caesarean section
Anil K Bhiwal, Seema Partani, Preeti Saini
Department of Anaesthesiology, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
|Date of Web Publication||7-Nov-2017|
Anil K Bhiwal
Department of Anaesthesiology, Geetanjali Medical College and Hospital, Udaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
A 37 years old primigravida, 31 weeks gestation with severe preeclampsia [BP = 180/120 mm Hg] with severe kyphoscoliosis and polio affecting right lower limb was admitted in emergency with complaint of blurring of vision and pedal edema. An emergency caesarean section was conducted under general anaesthesia because of a failed spinal anaesthesia. Perioperative anaesthetic management and her postoperative course are discussed.
Keywords: Kyphoscoliosis, perioperative management, renal failure, severe preeclampsia
|How to cite this article:|
Bhiwal AK, Partani S, Saini P. Peri-operative management of severe pre-eclampsia with kyphoscoliosis and poliomyelitis for emergency caesarean section. J Obstet Anaesth Crit Care 2017;7:109-11
|How to cite this URL:|
Bhiwal AK, Partani S, Saini P. Peri-operative management of severe pre-eclampsia with kyphoscoliosis and poliomyelitis for emergency caesarean section. J Obstet Anaesth Crit Care [serial online] 2017 [cited 2019 Dec 12];7:109-11. Available from: http://www.joacc.com/text.asp?2017/7/2/109/217773
| Introduction|| |
Severe pre-eclampsia can develop in approximately 25% of all cases of pre-eclampsia that can result in both acute and long-term complications. It can lead to decreased placental perfusion, placental ischemia and infarction, small for dates, placental abruption, and preterm labour. Liver failure, renal failure, respiratory failure, disseminated intravascular coagulopathy (DIC) and central nervous system (CNS) abnormalities can occur which is responsible for approximately 14% of maternal deaths. Poliomyelitis is associated with kyphoscoliosis in 30% of obstetric patients compared to its prevalence in general population of 0.3–15.3%. We report the peri-operative management for emergency cesarean section of a patient with severe pre-eclampsia and kyphoscoliosis with renal failure.
| Case Report|| |
A 37-year-old primgravida, 31 weeks gestation (height 140 cm, weight 45 kg) was admitted to the hospital with complaints of blurring of vision and pedal oedema. She was a known case of poliomyelitis and severe thoracolumbar kyphoscoliosis.
On examination, she was conscious, oriented and afebrile. Her heart rate was 100/min, blood pressure 180/120 mmHg, SPO2 97% with no dyspnoea, cyanosis or epigastric pain. Her preoperative laboratory investigations were Haemoglobin 11.3 gm%, Total leucocyte count 7300/mm 3, platelet 1.2 lac/mm 3, PT/INR 13/1.03, LDH 649 IU/L, urea 43 mg%, creatinine 0.70 mg%, SGOT 167 IU/L, SGPT 175 IU/L and urine albumin ++++.
Following a high-risk informed consent, an emergency caesarean section was planned in view of impending eclampsia. Inj. ranitidine 50 mg intravenously and inj. metoclopramide 10 mg intravenously was given for aspiration prophylaxis along with inj. labetalol 20 mg intravenously. Her urinary bladder was catheterised but no urine output was present. She was shifted to the operation theatre and intravenous infusion of 500 ml Ringer lactate was started. Pre-induction vital parameters showed HR = 102/min, BP = 178/115 mmHg with SpO2 97% on air.
Two attempts at lumbar puncture failed, so the procedure was abandoned and general anaesthesia was planned. Inj. xylocard 1.5 mg/kg intravenously was given which was followed by induction with inj. propofol 2 mg/kg and succinylcholine 1.5 mg/kg. Intubation with cricoid pressure was done with cuffed oral endotracheal tube no. 6.5 and anaesthesia was maintained with oxygen, nitrous oxide and sevoflurane without long acting muscle relaxant. Intra-operative monitoring was done by pulse oximeter, NIBP, ECG, and hourly urine output. A Pfannenstiel incision was made, and a female foetus was delivered weighing 1.7 kg with APGAR score of 5 at first min. and 7 at 5 min. Intravenous tramadol 100 mg was used as analgesia and BP was controlled by intermittent dose of inj. labetalol (20 mg). Total 650 ml ringer lactate was given intravensouly. On extubation, her HR was 106/min, BP was 170/116 mmHg, but there was no urine output in the urobag, so she was shifted to the intensive care unit (ICU) for further management.
In ICU, invasive blood pressure monitoring was started and blood pressure was controlled by labetalol infusion (40 mg/h). Urgent 2D ECHO was done which showed global LV hypokinesia, mild LVH diastolic dysfunction, sclerosed AV, mild AR and EF 45%. NTG infusion at a dose of 2 μg/kg/min was started and stopped after 8 hours when BP reached 130/80 mmHg. Subsequently, dobutamine infusion in dose of 5 μg/kg/min was started as ECHO findings showed global LV hypokinesia. Her urine output started initially at 25 ml/h after giving fluid challenge (250 ml bolus) and inj. Lasix 20 mg but after 6 h her urine output again stopped for next 12 h despite giving fluid (2100 ml) and inj. Lasix 40 mg intravenously.
On day 2, her investigations showed Hb 7.6 gm%, TLC 15300/mm 3, platelets 1.25 lakh/mm 3, bilirubin 0.3 mg%, SGOT 278 IU, SGPT 218 IU, protein 3.86 mg%, albumin 1.93 mg% globulin 1.93 mg%, TSH 7.67, creatinine 1.37 mg%. Her ultrasonography findings were normal. One unit PRBC was transfused, tab. thyroxine 25 μg and inj. Lasix 40 mg BD was started, as advised by nephrologist. NTG infusion was restarted and fluid was given at 60 ml/h. Her urine output again started at 30 ml/h and gradually increased. Her total urine output was 2175 ml in 24 h and total intravenous fluid intake was 1680 ml.
On day 3, dobutamine was stopped. BP was controlled with oral antihypertensive drugs (tab. clonidine 100 μg QID, tab. nicardia R 20 mg QID) along with NTG infusion. Her total intake was 1570 ml and output was 3260 ml. On day 4, NTG infusion and Lasix was stopped and BP was maintained around 150/90 mmHg. On day 5, she was shifted to the ward and oral antihypertensive drugs were continued. On day 6, as per cardiologist advice tab. losartan 40 mg and bisoprolol 2.5 mg was started. She was discharged on the 11th day with tab thyroxin, losartan and bisoprolol with BP 140/90 mmHg and adequate urine output.
| Discussion|| |
Severe pre-eclampsia is a condition in which the systolic BP ≥160 mmHg and diastolic BP ≥110 mmHg with proteinurea occurring after 20 weeks of gestation. Adequate management of pre-eclampsia involve antihypertensive therapy, seizure prophylaxis, facilitated delivery and critical care management.
Neuraxial techniques are preferred over general anaesthesia for cesarean delivery in the setting of severe preeclampsia as long as neuraxial anesthesia is not contraindicated. Specific indications for general anaesthesia for caesarean section include coagulopathy, pulmonary edema, imminent foetal distress and failed spinal anaesthesia.
General anaesthesia proves a challenge for the anaesthesiologist in kyphoscoliosis because of increased sensitivity to sedative drugs, prolonged effect of nondepolarizing neuromuscular blocking agents, dysfunctional autonomic nervous system and underdeveloped respiratory muscles. All these factors may lead to delay in extubation and need for postoperative ventilation.
Central neuraxial technique is also challenging in view of identifying the intervertebral space, performing lumbar puncture and difficulty in predicting the extent of block because of the distortion of the spinous process and rotation of the vertebral column. Use of ultrasound for locating the space for neuraxial block would have improved the success of block. We had initially attempted spinal anaesthesia for LSCS but had to resort to general anaesthesia due to failure of spinal anaesthesia.
Antihypertensive drugs that can be safely used include labetalol (oral or intravenous), methyldopa, nifedipine (oral) and intravenous hydralazine. Post-operatively, we used intravenous infusion of labetalol (40 mg/h) and then NTG infusion. Intra-arterial BP monitoring can facilitate detection and accurate treatment of blood pressure changes while echocardiography can provide information about volume status and cardiac function, and thus preventing any multiorgan damage in the postpartum period., We did not use magnesium sulphate in our patient because patient had decreased urine output.
Normal urine output could be maintained at 25 ml/h with diuretics and intravenous fluid challenge (250 ml) initially for 6 h but subsequently anuria occurred, which was unresponsive to above management till day 2. This could have resulted due to acute tubular necrosis, which is commonly seen in 83–90% of patients with severe preeclampsia or it could be consequent to severe dehydration. Serum creatinine levels had increased up to 1.42 mg% due to anuria and urine albumin was ++++ on day 1. Correcting fluid and electrolyte imbalance, maintaining blood pressure and adequate nutrition in the post-operative period should be ensured. Transaminases were increased marginally, however, serum bilirubin levels were normal and coagulation profile including platelets were within normal range, excluding any suspicion of HELLP syndrome.
The neonate was premature, low birth weight and required neonatal ICU management which prolonged the hospital stay of both mother and neonate.
| Conclusion|| |
This case report demonstrates that multidisciplinary ICU management in the postoperative period ensured a positive maternal and neonatal outcome, in this patient.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006;367:1066-74.
Lonstein JE. Adolescent idiopathic scoliosis. Lancet 1994;344:1407-12.
Henke VG, B ateman BT, Leffert LR. Focused review: spinal anesthesia in severe preeclampsia. Anesth Analg 2013;117:686-93.
Gupta S, Singariya G. Kyphoscolisis and pregnancy – A case report. Indian J Anaesth 2004;48:215-20. [Full text]
Ballarapu GK, Aloka S, Veldurti AKK, Padmaja D, Gudaru J. Spinal anesthesia in poliomyelitis patients with scoliotic spine: A case control study. Indian J Anaesth 2013;57:145-9.
Chin KJ, Chan VW, Ramlogan R, Perlas A. Real time ultrasound guided spinal anesthesia in patients with a challenging spinal anatomy: Two case reports. ActaAnaesthesiol Scand 2010;54:252-5.
Podymow T, August P. Update on the use of antihypertensive drugs in pregnancy. Hypertension 2008;51:960-9.
Dennis AT. Transthoracic echocardiography in obstetric anaesthesia and obstetric critical illness. International Journal of Obstetric Anesthesia 2011;20:166-8.
Montenij LJ, de Waal EE, Buhre WF. Arterial waveform analysis in anesthesia and critical care. CurrOpinAnaesthesiol 2011;24:651-6.
Moran P, Lindheimer MD, Davison JM. The renal response to preeclampsia. Semin Nephrol 2004;24:588-95.