Anesthetic management in Impending Eclampsia with Intracranial Pathology

   

Srashti Singh^1* and  Sandeep Kadam²

Citation: Singh S, Kadam S. (2022) Anesthetic management in Impending Eclampsia with Intracranial Pathology. Adv Clin Med Res. 3(4):1-4.

Received: October 13,  2022 | Published: October 25, 2022

Copyright^©2022 genesis pub by Singh S, et al. CC BY-NC-ND 4.0 DEED. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivatives 4.0 International License.,This allows others distribute, remix, tweak, and build upon the work, even commercially, as long as they credit the authors for the original creation.

DOI: https://doi.org/10.52793/ACMR.2022.3(4)-43

Introduction

Intracranial bleed is rare yet devastating event in pregnancy. There are risk of maternal mortality/morbidity and poor fetal outcome. Intracranial hemorrhage can be subdural, extradural, subarachnoid, intraparenchymal. Causes of bleeding include trauma, jaundice, preeclampsia, eclampsia, venous thrombosis. Urgent neurosurgical, obstetrician and anesthetic intervention needs to be taken for better maternal and fetal outcome.

Case Presentation

We report a case of 22 yrs. old primigravida patient with 34 week of gestation came to hospital with complaint of giddiness and 2 episodes of vomiting since morning. Her GCS was 10/15. Patient was diagnosed with Impending Eclampsia with fetal de-stress and provisional diagnosis of ICH. Prichard regimen (mgso4) was given. Emergency lower segment cesarean section was done in view of fetal de-stress and Right sided de-compressive emergency craniotomy was done later [1,2].

On examination

• Patient was irritable
• Temperature Afebrile
• Heart Rate : 110 bpm
• Blood pressure : 140/90 mmHg
• CVS : S1S2 heard
• RS : AEEBS
• No pallor, no icterus, no cyanosis, no oedema.

Investigations

• CBC :Hb 12.8 gm/dl , Plt 1,47,000 ,
• TLC 7,800.
• RFT  : Urea 18.7 , Creatinine 0.8
• LFT : WNL
• PT/INR : 14/14/1.10
• ECG :WNL

Management

• Difficult airway cart and emergency drugs were kept ready , informed valid written consent , high risk consent were taken. Premedication with Inj. Glycopyrrolate 0.2mg, Inj. Ondansetron4mg , Inj. fentanyl 50 mcg , Inj. Loxicard 60 mg i/v was given.
• general anesthesia was given using rapid sequence intubation using video laryngoscope .
• Induction was done. Inj. Propofol 100mg and Inj. Succinylcholine100mg, Intubation was done using cuffed endotracheal tube no. 7.00 cm, Patient was maintained on O2 + Air+ Sevoflurane and vecuronium.
• After delivering of baby, inj. Loxicard 60 mg iv and inj. Fentanyl 50 mcg iv was given.
• After completion of surgery patient was extubated shifted to SICU.
•  Later on next morning patient became drowsy again .emergency neurologist opinion was taken and MRI was done which showed ICH. Patient was immediately shifted to operation theater and right sided de-compressive surgery was done , after completion of surgery patient was shifted to sicu and electively ventilated for 3 days on SIMV and later extubated.
• Patient neurologically improved and comes for follow up .
• Both mother and baby are healthy.

On MRI

Large temporal lobe capsuloganglionic intracerebral hematoma (80*42mm), Effacement of ipsilateral right lateral ventricle, midline shift of approx.1.2 cm towards left suggestive of falcine herniation (Figure 1).

 

 

Figure 1: Large temporal lobe capsuloganglionic intracerebral hematoma (80*42mm), Effacement of ipsilateral right lateral ventricle, midline shift of approx.1.2 cm towards left suggestive of falcine herniation.

On CT Brain Plain

Interparenchymal hemorrhage in right fronto-  parieto-temporal region with mild to moderate perilesionaloedema causing significant mass effect and midline shift of 7 mm to the left as described above. There is intraventricular extension of bleed into the occipital horn of left lateral ventricle. There were changes of cerebral edema.

Discussion 

A thorough preoperative evaluation is crucial to plan for definitive intraoperative and postoperative management and we should keep backup plan ready in case of any untoward complication such as Difficult intubation, aspiration, Hypertension/Hypotension, intrapartum or postpartum hemorrhage. In case of parturient patient with giddiness first thing comes to our mind is Hypertensive diseases of pregnancy and its complications. As we saw disorientation, we immediately thought of that but as other parameters like normal LFT and no proteinuria, we thought of doing MRI to evaluate any intracranial.

Conclusion

Even in cases of pregnant patient apart from PIH and Preeclampsia, we have to keep our mind to open in view of Intracranial pathology like intracranial hematoma.

References

1. Aoyama K, Ray JG. (2020) Pregnancy and Risk of Intracerebral Hemorrhage. JAMA Netw Open. 3(4):e202844.
2. Ascanio LC, Maragkos GA, Young BC, Boone MD, Kasper EM. (2019) Spontaneous Intracranial Hemorrhage in Pregnancy: A Systematic Review of the Literature. Neurocrit Care. 30(1):5-15.