Obstetrical anaesthesia for a parturient with preeclampsia, HELLP syndrome and acute cortical blindness

Evaluating hemostatic thresholds for neuraxial anesthesia in adults with hemorrhagic disorders and tendencies: A scoping review

Neuraxial anesthesia can be complicated by spinal or epidural hematoma and may result in permanent neurologic injury. There is a paucity of literature characterizing this serious complication in patients with congenital and acquired hemorrhagic disorders or tendencies. The objective of this scoping review was to describe the hemostatic laboratory parameters where neuraxial anesthesia has been administered with and without spinal and epidural hematoma in patients with preexisting hemorrhagic disorders and tendencies, including immune thrombocytopenia, gestational thrombocytopenia, thrombocytopenia associated with hypertensive disorders of pregnancy, platelet function disorders, von Willebrand disease, coagulation factor deficiencies, and fibrinogen disorders. A systematic search of Ovid MEDLINE, CINAHL, Embase, Scopus, and Web of Science was performed. Two authors independently reviewed all titles, abstracts, and full texts to determine study eligibility and extract data. Qualitative synthesis of 91 studies revealed significant gaps in our understanding of the risk of spinal and epidural hematoma in patients with hemorrhagic disorders and tendencies, including few studies of males and in nonobstetric settings. Most reviewed articles were small, retrospective studies at high risk for potential bias. With such low-quality data, we were unable to provide any true estimates of the risk of spinal or epidural hematoma for these patients, nor could we attribute any specific hemostatic or laboratory values to increased risk of hematoma. There is a need both for larger and more rigorously designed and reported studies on this subject and for structured, comprehensive recommendations for safe administration and removal of neuraxial anesthesia in patients with hemorrhagic disorders and tendencies.

Anesthetic considerations in HELLP syndrome

BACKGROUND

HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is an obstetric complication with heterogonous presentation and multisystemic involvement. It is characterized by microangiopathic hemolytic anemia, elevated liver enzymes by intravascular breakdown of fibrin in hepatic sinusoids and reduction of platelet circulation by its increased consumption.

METHODS

In terms of these patients' anesthetic management, it is essential to consider some details: (1) effective, safe perioperative management by a multidisciplinary approach, and quick, good communication among clinical specialists to achieve correct patient management; (2) neuroaxial block, particularly spinal anesthesia, is the first choice to do the cesarean if there is only moderate, but not progressive thrombocytopenia; (3) if a general anesthesia is required, it is necessary to control the response to stress produced by intubation, especially in patients with either severe high blood pressure or neurological signs, or to prevent major cerebral complications; (4) invasive techniques, e.g., as tracheostomy, arterial, and deep-vein canalization, should be considered; (5) if contraindication for neuroaxial anesthesia exists, rapid sequence intubation with general anesthesia should be regarded as an emergency in patients with full stomach; (6) increased risk of difficult airways should be taken into account.

RESULTS

Optimal patient management can be chosen after considering the risks and benefits of each anesthetic technique, and based on good knowledge of these patients' pathophysiological conditions.

CONCLUSION

Later, close patient monitoring is recommended for potential development of hemorrhagic complications, disseminated intravascular coagulation (DIC), or eclampsia.

Bilateral Vision Loss after Delivery in Two Cases: Severe Preeclampsia and HELLP Syndrome

Two patients with no symptoms of hypertension in their medical history before pregnancy were referred to the obstetrics emergency clinic with hypertension and visual complaints. After physical examination and laboratory tests, one of the patients was diagnosed with severe preeclampsia while the other was diagnosed with HELLP syndrome (Hemolysis-Elevated Liver enzymes-Low Platelets). Ocular examinations were performed after delivery due to the patients’ worsening visual complaints. The severe preeclamptic patient showed bilateral serous retinal detachment (SRD) while the patient with HELLP syndrome showed bilateral macular hemorrhage. Systemic blood pressure control was advised. The patients’ ocular findings and visual acuities improved in the follow-up periods. SRD and macular hemorrhage can be observed in patients with preeclampsia and HELLP syndrome as a result of the disruption of retinal and choroidal vasculature.

Balancing the benefits and risks: lessons learned from the therapeutic interventions of a case with severe preeclampsia

BACKGROUND AND OBJECTIVE

Preeclampsia is a multiple organ dysfunction syndrome (MODS) for its typical and atypical manifestations including hypertension, proteinuria, HELLP syndrome, hypertensive encephalopathy and coagulopathy. Optimal management for such patients is determined from an assessment of the balance between benefits and risks of anesthetic and obstetric therapeutic strategies.

CASE REPORT

A 35-year-old pregnant woman, with one past uncomplicated pregnancy presented at 29 weeks to our medical institute as an emergency with dizziness, chest distress, palpitation, blurred vision and vaginal bleeding. After physical examination and laboratory tests, the patient was diagnosed with severe preeclampsia, HELLP syndrome, placental abruption, and MODS. The patient also presented spinal and pelvic deformity, fixation of articulus mandibularis, and tracheal displacement because of a traffic accident 11 years ago. Therefore, urgent cesarean section was performed under general anesthesia with nasal tracheal intubation using a guide wire. The patient was discharged directly home from the obstetric intensive care unit on the 7(th) postoperative day with normal blood pressure and full recovery of organic function.

CONCLUSIONS

This case merits further discussion on the anesthesia considerations concerning how to make a clinical decision when treating such a patient. Neuraxial block is the first choice for preeclampsia patients undergoing cesarean section when a moderate but not progressive thrombocytopenia exists. When general anesthesia is decided, adequate sedation and analgesia is needed to better control the stress response to intubation especially in patients with neurological signs, and to prevent major cerebral complications.

Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy

OBJECTIVE

This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation and treatment of the hypertensive disorders of pregnancy (HDP).

EVIDENCE

The literature reviewed included the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines from 2008 and their reference lists, and an update from 2006. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT) and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2006 and March 2012. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care and GRADE.

Spinal anesthesia for lower segment Cesarean section in patients with stable eclampsia

STUDY OBJECTIVE

To report the use of spinal anesthesia in stable eclamptic patients.

DESIGN

Prospective case series.

SETTING

Emergency operating room of a metropolitan hospital.

PATIENTS

12 "stable" eclamptic parturients.

INTERVENTIONS

Subarachnoid block was instituted with hyperbaric 0.5% bupivacaine 1.7 mL with fentanyl 25 μg.

MEASUREMENTS

Intraoperative maternal hypotension, episodes of convulsion, the need to convert to general anesthesia, and Apgar scores at 1 and 5 minutes were recorded.

MAIN RESULTS

Only one of the 12 parturients had an episode of hypotension (treated by intravenous ephedrine), while no patient had a convulsion over the 48 hours after delivery. The sensory level achieved was T₅-T₆ and none of the cases was converted to general anesthesia. Median Apgar scores at 1 and 5 minutes were 8 and 9, respectively.

CONCLUSION

Spinal anesthesia avoided the known risks of general anesthesia and was not associated with any major complications.

Characteristic laboratory changes in pregnancies complicated by HELLP syndrome

INTRODUCTION

HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is a severe, life-threatening form of preeclampsia. Its development is accompanied by significant increase in maternal, as well as fetal, morbidity, and mortality rates. It is essential, therefore, for obstetricians to be familiar with the disease.

MATERIALS AND METHODS

In the past 10 years, 107 patients were treated for HELLP syndrome in the intensive care unit (ICU) of the First Department of Obstetrics and Gynaecology, Semmelweis University. During this time, we studied the characteristic laboratory findings of the disease from the day of the diagnosis until the first few postpartum days.

RESULTS

HELLP syndrome was present in 0.37% of all women having live births. In our study, the liver enzymes AST, and LDH, and the level of total bilirubin (indicating the degree of hemolysis), and repeated thrombocyte counts were suitable for following the cases. The AST, LDH and bilirubin levels returned to normal between the third and seventh days postpartum. The platelet count passed the critical level of 100,000/microL on the third to fourth day.

CONCLUSIONS

We have found that the platelet count, LDH, AST, and total bilirubin levels proved to be useful indicators of the progression of HELLP syndrome.

Transient cortical blindness after resuscitation in a child having central venous catheterization under general anesthesia

We describe a case of chronic renal failure developing life-threatening cardiovascular collapse during the insertion of central venous catheter for hemodialysis under general anesthesia in a 7-year-old boy. With timely resuscitation, he regained his vital signs within 20 min. However, after admission to the pediatric intensive care unit, visual impairment and four limb weakness were detected on the first postoperative day. Fortunately, symptoms resolved completely with close observation, psychological support and conservative management within 72 h without sequelae.

Permanent visual deficits secondary to the HELLP syndrome

A 34-year-old woman with eclampsia and the hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome developed encephalopathy, cardiomyopathy, pulmonary edema, liver failure, and disseminated intravascular coagulation (DIC), all of which resolved. She also had retinal hemorrhages in both eyes and a hemorrhagic infarct in the left occipital lobe that resulted in a permanent right homonymous hemianopia and a persistently depressed acuity of 20/100 OS. This case is unusual in demonstrating permanent visual deficits. In nearly all cases of preeclampsia or eclampsia, visual deficits are reversible. The superimposition of the HELLP syndrome may create more neurologic damage. Clinicians should be alert to patients at risk for HELLP syndrome and manage them aggressively.

Anesthetic management of Cesarean delivery in a patient with hypoplastic anemia and severe pre-eclampsia

PURPOSE

To describe the anesthetic management of Cesarean delivery in a patient with hypoplastic anemia and severe pre-eclampsia.

CLINICAL FEATURES

A 28-yr-old parturient with a history of thrombocytopenia was admitted with signs of pre-eclampsia (blood pressure of 140/90 mmHg, heavy proteinuria and moderate bilateral ankle edema) at 25 weeks of gestation. Laboratory studies revealed pancy-topenia (hemoglobin 6.4 g.dL(-1), white cell count 3.43 x 10(9).L(-1), platelet count 20 x 10(9).L(-1)) and bone marrow biopsy showed hypoplastic anemia. As pre-eclampsia worsened, a Cesarean delivery was performed at 27 weeks with prophylactic platelet transfusion and meticulous blood pressure control. The procedure was uneventful, conducted under general anesthesia with an estimated blood loss of around 600 mL and a live female baby was delivered. Postoperatively her blood pressure and neurological symptoms improved but thrombocytopenia remained at discharge.

CONCLUSIONS

Hypoplastic anemia is rare in pregnancy but it poses an increased risk for both mother and fetus. The mother is at risk of life-threatening episodes of bleeding and infection and a multidisciplinary team approach (obstetrician, anesthesiologist, hematologist and pediatrician) is essential. An accurate assessment of the hematological condition should be made and abnormalities corrected before surgery. Regional anesthesia may not be possible in this circumstance.

Cerebral haemodynamic pathologies in HELLP syndrome

The syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP syndrome) is understood as a unique variant of severe preeclampsia. This disorder complicates between 2 and 7% of gestations and is associated with a high perinatal morbidity and a maternal morbidity ranging between 1 and 4%. Intracerebral complications only rarely occur, especially intracerebral haemorrhage was described only in single cases, often correlated with fatal maternal outcome. The analysis of patients with HELLP syndrome treated at our hospital revealed three cases with severe neurological deterioration. Possible pathogenetic factors are discussed.

Late occurrence of diffuse cerebral swelling after intracerebral hemorrhage in a patient with the HELLP syndrome--Case report

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome can occur at any time in the course of pregnancy and is associated with many complications including fatal stroke. A 37-year-old female presented with HELLP syndrome causing an intracerebral hematoma, which was treated by evacuation and mild hypothermia. Unexpected diffuse cerebral swelling occurred on the 15th day of the initially favorable postoperative course. Considerable impairment of consciousness persisted despite conservative therapy. Serial computed tomographic findings indicated delayed cerebral vasospasm as the cause of the swelling. Particularly careful management is required even beyond the first 2 weeks for patients with stroke as a complication of HELLP syndrome.

Acute onset of blindness during labor: report of a case of transient cortical blindness in association with HELLP syndrome

The coincidence of HELLP syndrome and cortical blindness is an uncommon but very dramatic event, for the patient as well as the obstetrician. This report describes the first case of HELLP-syndrome-associated cortical blindness occuring suddenly in the third stage of labour. There were only modest correlates of cortical blindness in cerebral CT, MRI and angiography findings, but no signs of a posterior leucoencephalopathy syndrome. Mother and baby were discharged from hospital to outpatient care in good health on the 12th day.