UBP 1.3 (Long Form): Obstetrics – Preeclampsia/Eclampsia

Question 1

Intra-operative Management:

The baby’s heart tones are still down, you have not yet intubated the patient, and the decision is made to perform an emergency c/s.

Would you consider a regional anesthetic?

• (A 29-year-old 5’7” 105 kg G1P0 female presents at 34 weeks gestation to the obstetric floor following emergency transport from a small rural town.*
• HPI: The patient’s husband found her unconscious on the kitchen floor. She was taken by ambulance to the hospital where she received a loading dose of magnesium and 10 mg of Ativan. The referring hospital’s E.R. physician placed a nasal “trumpet” and had her transported to your obstetric service.*
• PMH: A family member informs you that the patient has HIV.*
• PE: Vital Signs: P = 83, BP = 148/92, R = 16, T = 37 ºC*
• Airway: Her tongue is swollen and appears to have been bitten; further visual evaluation of the oropharynx is inhibited by the large, swollen tongue.*
• CV: RRR*
• Lungs: CTA Bilaterally*
• Gen: Edema of the face and extremities noted*
• Lab: H/H = 13.1/37 Platelets = 138 urine = 3+ protein)*

Answer 1

Given the potential for further deterioration of her mental state, with subsequently increased risk for aspiration and/or hypoventilation,

I would proceed with a general anesthetic and a secured airway.

Once the airway was secured, controlled ventilation would be helpful in avoiding hypoventilation-induced hypercapnia, hypoxia, and respiratory acidosis, which could place her at increased risk for inadequate cerebral perfusion (she may be experiencing elevated ICP secondary to edema formation or hemorrhage) and/or hemolysis (G6PD deficiency).

Other reasons a regional anesthetic may be less desirable include:

1. the risk of sympathectomy-induced hypotension (especially with a spinal anesthetic), which could compromise cerebral perfusion in the presence of elevated ICP;
2. her inability to cooperate, which would make providing a regional anesthetic technically difficult when time is of the essence; and,
3. the theoretical risk of an unintentional dural puncture leading to brain stem herniation (Theoretically, the loss of cerebral spinal fluid from the spinal compartment, in the presence of increased ICP, could lead to a life-threatening pressure gradient between the cerebral and spinal compartments.).

While the risk of epidural or spinal hematoma secondary to thrombocytopenia and thrombocytopathia is always a concern when providing a neuraxial anesthetic in the presence of eclampsia, her platelet count appears to be adequate for good homeostasis.

However, I recognize that the performance of general anesthesia carries a significant risk of difficult airway management in this situation, including apnea, inability to intubate, and aspiration.

Therefore, prior to attempting to secure her airway for general anesthesia, I would provide aspiration prophylaxis, have difficult airway equipment available, and ensure the presence of a surgeon capable of establishing a surgical airway should it become necessary.

• Clinical Note:*
• This is a situation where the planned establishment of a surgical airway should be considered.

Question 2

Intra-operative Management:

Is it acceptable to place a neuraxial block in a patient with HIV?

• (A 29-year-old 5’7” 105 kg G1P0 female presents at 34 weeks gestation to the obstetric floor following emergency transport from a small rural town.*
• HPI: The patient’s husband found her unconscious on the kitchen floor. She was taken by ambulance to the hospital where she received a loading dose of magnesium and 10 mg of Ativan. The referring hospital’s E.R. physician placed a nasal “trumpet” and had her transported to your obstetric service.*
• PMH: A family member informs you that the patient has HIV.*
• PE: Vital Signs: P = 83, BP = 148/92, R = 16, T = 37 ºC*
• Airway: Her tongue is swollen and appears to have been bitten; further visual evaluation of the oropharynx is inhibited by the large, swollen tongue.*
• CV: RRR*
• Lungs: CTA Bilaterally*
• Gen: Edema of the face and extremities noted*
• Lab: H/H = 13.1/37 Platelets = 138 urine = 3+ protein)*

Answer 2

HIV alone is not a contraindication to regional anesthesia.

While there is some concern that potential transmission of the virus to the subarachnoid space (unintentional dural puncture, blood patch) could accelerate the central nervous system manifestations of the disease, there is NO evidence of increased infectious or neurologic complications secondary to regional anesthesia.

In fact, CNS infection with HIV likely occurs very early in the disease process.

Question 3

Intra-operative Management:

You decide to perform a general anesthetic.

Do you need an art-line?

• (A 29-year-old 5’7” 105 kg G1P0 female presents at 34 weeks gestation to the obstetric floor following emergency transport from a small rural town.*
• HPI: The patient’s husband found her unconscious on the kitchen floor. She was taken by ambulance to the hospital where she received a loading dose of magnesium and 10 mg of Ativan. The referring hospital’s E.R. physician placed a nasal “trumpet” and had her transported to your obstetric service.*
• PMH: A family member informs you that the patient has HIV.*
• PE: Vital Signs: P = 83, BP = 148/92, R = 16, T = 37 ºC*
• Airway: Her tongue is swollen and appears to have been bitten; further visual evaluation of the oropharynx is inhibited by the large, swollen tongue.*
• CV: RRR*
• Lungs: CTA Bilaterally*
• Gen: Edema of the face and extremities noted*
• Lab: H/H = 13.1/37 Platelets = 138 urine = 3+ protein)*

Answer 3

I would place an arterial line to closely monitor and treat her blood pressure, which would be critically important in maintaining adequate cerebral perfusion pressure and/or preventing increased ICP.

While an arterial line would be helpful in closely monitoring and treating any hemodynamic changes that occurred during induction and intubation, I would not delay securing the airway of this obtunded patient, or the delivery of this distressed baby, for arterial line placement.

I would, however, place the arterial line as soon as it became feasible.

Question 4

Intra-operative Management:

The baby is delivered and the mother’s blood pressure increases to 189/105 and her heart rate decreases to 48.

Moreover, her left pupil is dilated and not reactive to light.

What do you think might be going on?

• (A 29-year-old 5’7” 105 kg G1P0 female presents at 34 weeks gestation to the obstetric floor following emergency transport from a small rural town.*
• HPI: The patient’s husband found her unconscious on the kitchen floor. She was taken by ambulance to the hospital where she received a loading dose of magnesium and 10 mg of Ativan. The referring hospital’s E.R. physician placed a nasal “trumpet” and had her transported to your obstetric service.*
• PMH: A family member informs you that the patient has HIV.*
• PE: Vital Signs: P = 83, BP = 148/92, R = 16, T = 37 ºC*
• Airway: Her tongue is swollen and appears to have been bitten; further visual evaluation of the oropharynx is inhibited by the large, swollen tongue.*
• CV: RRR*
• Lungs: CTA Bilaterally*
• Gen: Edema of the face and extremities noted*
• Lab: H/H = 13.1/37 Platelets = 138 urine = 3+ protein)*

Answer 4

This clinical picture is consistent with a Cushing response, where an increase in ICP leads to cerebral ischemia with a subsequent increase in arterial blood pressure, reflex slowing of the heart rate, and the development of irregular respirations (some sources substitute a widened pulse pressure - increased difference between systolic and diastolic blood pressure - as the third component of the triad, in place of an irregular respiratory pattern).

Moreover, her dilated and nonreactive pupil is suggestive of cranial nerve III compression (oculomotor) secondary to uncal herniation.

Therefore, I would immediately take measures to reduce her ICP, such as discontinuing volatile agents, making sure there is no venous obstruction, elevating the head 30º to facilitate venous drainage, and hyperventilating the patient to induce cerebral vasoconstriction.

Question 5

Intra-operative Management:

Would you give mannitol?

• (A 29-year-old 5’7” 105 kg G1P0 female presents at 34 weeks gestation to the obstetric floor following emergency transport from a small rural town.*
• HPI: The patient’s husband found her unconscious on the kitchen floor. She was taken by ambulance to the hospital where she received a loading dose of magnesium and 10 mg of Ativan. The referring hospital’s E.R. physician placed a nasal “trumpet” and had her transported to your obstetric service.*
• PMH: A family member informs you that the patient has HIV.*
• PE: Vital Signs: P = 83, BP = 148/92, R = 16, T = 37 ºC*
• Airway: Her tongue is swollen and appears to have been bitten; further visual evaluation of the oropharynx is inhibited by the large, swollen tongue.*
• CV: RRR*
• Lungs: CTA Bilaterally*
• Gen: Edema of the face and extremities noted*
• Lab: H/H = 13.1/37 Platelets = 138 urine = 3+ protein)*

Answer 5

Considering her significant risk for brainstem herniation, I would consider administering mannitol if other methods of treatment were unsuccessful in order to reduce her ICP by

1. osmotically shifting fluid from the intracranial compartment to the intravascular compartment,
2. decreasing the production of CSF, and
3. inducing reflex cerebral vasoconstriction (secondary to decreased blood viscosity).

However, I would reserve this treatment modality until other measures had failed, because mannitol could potentially worsen cerebral edema if the blood brain barrier is not intact and, in the case of intracranial bleeding, it could lead to the expansion of an intracranial hematoma as the surrounding brain tissue shrinks with osmotic diuresis.

Question 6

Post-operative Management:

The case is over and the patient is taking longer than expected to wake up.

What will you do?

• (A 29-year-old 5’7” 105 kg G1P0 female presents at 34 weeks gestation to the obstetric floor following emergency transport from a small rural town.*
• HPI: The patient’s husband found her unconscious on the kitchen floor. She was taken by ambulance to the hospital where she received a loading dose of magnesium and 10 mg of Ativan. The referring hospital’s E.R. physician placed a nasal “trumpet” and had her transported to your obstetric service.*
• PMH: A family member informs you that the patient has HIV.*
• PE: Vital Signs: P = 83, BP = 148/92, R = 16, T = 37 ºC*
• Airway: Her tongue is swollen and appears to have been bitten; further visual evaluation of the oropharynx is inhibited by the large, swollen tongue.*
• CV: RRR*
• Lungs: CTA Bilaterally*
• Gen: Edema of the face and extremities noted*
• Lab: H/H = 13.1/37 Platelets = 138 urine = 3+ protein)*

Answer 6

I would check her vital signs and ensure adequate blood pressure, oxygenation, and ventilation.

Since this is possibly a manifestation of worsening cerebral pathology, I would consult a neurosurgeon, plan for immediate transport to obtain a CT of her head, and continue to take steps to reduce ICP and maintain adequate cerebral perfusion pressure.

Other potential causes include – magnesium toxicity or the high dose narcotics used during the case.

However, I would be hesitant to reverse the narcotics since a reversal of pain control could result in a sympathetic surge with subsequent exacerbation of her cerebral pathology.

I would also be hesitant to discontinue the magnesium infusion due to the continued risk of seizure.

Question 7

Post-operative Management:

You are getting ready to go for CT and notice a widened QRS complex on EKG.

What will you do?

• (A 29-year-old 5’7” 105 kg G1P0 female presents at 34 weeks gestation to the obstetric floor following emergency transport from a small rural town.*
• HPI: The patient’s husband found her unconscious on the kitchen floor. She was taken by ambulance to the hospital where she received a loading dose of magnesium and 10 mg of Ativan. The referring hospital’s E.R. physician placed a nasal “trumpet” and had her transported to your obstetric service.*
• PMH: A family member informs you that the patient has HIV.*
• PE: Vital Signs: P = 83, BP = 148/92, R = 16, T = 37 ºC*
• Airway: Her tongue is swollen and appears to have been bitten; further visual evaluation of the oropharynx is inhibited by the large, swollen tongue.*
• CV: RRR*
• Lungs: CTA Bilaterally*
• Gen: Edema of the face and extremities noted*
• Lab: H/H = 13.1/37 Platelets = 138 urine = 3+ protein)*

Answer 7

Since the most likely causes of a widened QRS complex in this case are –

1. a previous condition,
2. elevated intracranial pressure,
3. subarachnoid hemorrhage, or
4. magnesium toxicity,

I would –

• check her vital signs,
• look at the most recent EKG,
• continue efforts to control ICP,
• draw a magnesium level,
• check deep tendon reflexes for hyporeflexia, and
• proceed to CT to rule out intracranial hemorrhage.

Given the long half-life of magnesium, I would –

• discontinue the infusion temporarily and wait for the lab results to return while at the same time being prepared to quickly treat a seizure should one occur.

If the lab work and/or physical exam supported the diagnosis of magnesium toxicity, and assuming renal function was adequate despite her eclampsia, I would–

• administer a diuretic to increase renal excretion, and calcium gluconate to antagonize the neurologic and cardiac effects of magnesium.

Clinical Notes: Magnesium Toxicity Levels:

(See Figure below)

Question 8

Post-operative Management:

On post-op day two her magnesium levels have returned to normal, but the patient becomes jaundiced and develops dark colored urine.

What would you do?

• (A 29-year-old 5’7” 105 kg G1P0 female presents at 34 weeks gestation to the obstetric floor following emergency transport from a small rural town.*
• HPI: The patient’s husband found her unconscious on the kitchen floor. She was taken by ambulance to the hospital where she received a loading dose of magnesium and 10 mg of Ativan. The referring hospital’s E.R. physician placed a nasal “trumpet” and had her transported to your obstetric service.*
• PMH: A family member informs you that the patient has HIV.*
• PE: Vital Signs: P = 83, BP = 148/92, R = 16, T = 37 ºC*
• Airway: Her tongue is swollen and appears to have been bitten; further visual evaluation of the oropharynx is inhibited by the large, swollen tongue.*
• CV: RRR*
• Lungs: CTA Bilaterally*
• Gen: Edema of the face and extremities noted*
• Lab: H/H = 13.1/37 Platelets = 138 urine = 3+ protein)*

Answer 8

These symptoms are consistent with –

hemolytic anemia, a complication known to be associated with G6PD deficiency.

Therefore, I would:

1. evaluate the patient for other signs of hemolytic anemia, such as pallor, shortness of breath, fatigue, and substernal pain;
2. order a –
   
   • complete blood count (anemia),
   • reticulocyte count (increases in 4-7 days),
   • peripheral blood smear (looking for the presence of Heinz bodies),
   • liver function tests (increased bilirubin), and a
   • urinalysis (hemosiderin, urobilinogen, and brown color);
3. eliminate any precipitating factors, such as hypothermia, acidosis, hypoxia, hyperglycemia, infection, fava beans, chemicals (methylene blue and antimalarials), and certain drugs (i.e. nitrofurantoin, chloramphenicol, co-trimoxazole, high dose aspirin, methyldopa, hydralazine, procainamide, and quinidine);
4. administer fluids and mannitol to maintain urine output (mannitol has antioxidant and free radical scavenging properties in addition to its osmotic effects); and
5. consider transfusion, if necessary.

Clinical Notes:

• Hemolysis usually occurs 2-5 days following drug exposure and is usually self-limited (only the older red blood cells are affected).
• Think about G6PD deficiency when a patient experiences early postoperative hemolysis.

Question 9

Post-operative Management:

While you are evaluating the patient, the post-op nurse sticks herself drawing blood and is worried about contracting HIV.

What will you tell her?

• (A 29-year-old 5’7” 105 kg G1P0 female presents at 34 weeks gestation to the obstetric floor following emergency transport from a small rural town.*
• HPI: The patient’s husband found her unconscious on the kitchen floor. She was taken by ambulance to the hospital where she received a loading dose of magnesium and 10 mg of Ativan. The referring hospital’s E.R. physician placed a nasal “trumpet” and had her transported to your obstetric service.*
• PMH: A family member informs you that the patient has HIV.*
• PE: Vital Signs: P = 83, BP = 148/92, R = 16, T = 37 ºC*
• Airway: Her tongue is swollen and appears to have been bitten; further visual evaluation of the oropharynx is inhibited by the large, swollen tongue.*
• CV: RRR*
• Lungs: CTA Bilaterally*
• Gen: Edema of the face and extremities noted*
• Lab: H/H = 13.1/37 Platelets = 138 urine = 3+ protein)*

Answer 9

I would tell her that she should immediately wash the wound with soap and water and then report to employee health so they can draw blood for further testing.

I would also attempt to reassure her by telling her the transmission rate, even with percutaneous exposure to an HIV-positive source, is only about 0.3%.

Finally, I would tell her that she is likely to receive post-exposure prophylaxis and should avoid activities that risk transmitting the disease such as blood donation or sexual activity until follow-up laboratory testing is negative for HIV.

Question 10

Post-operative Management:

On the patient’s third post-op day, you respond to a code to find she is experiencing pulseless electrical activity (PEA).

What will you do?

• (A 29-year-old 5’7” 105 kg G1P0 female presents at 34 weeks gestation to the obstetric floor following emergency transport from a small rural town.*
• HPI: The patient’s husband found her unconscious on the kitchen floor. She was taken by ambulance to the hospital where she received a loading dose of magnesium and 10 mg of Ativan. The referring hospital’s E.R. physician placed a nasal “trumpet” and had her transported to your obstetric service.*
• PMH: A family member informs you that the patient has HIV.*
• PE: Vital Signs: P = 83, BP = 148/92, R = 16, T = 37 ºC*
• Airway: Her tongue is swollen and appears to have been bitten; further visual evaluation of the oropharynx is inhibited by the large, swollen tongue.*
• CV: RRR*
• Lungs: CTA Bilaterally*
• Gen: Edema of the face and extremities noted*
• Lab: H/H = 13.1/37 Platelets = 138 urine = 3+ protein)*

Answer 10

In managing PEA, I would:

1. initiate cardiopulmonary resuscitation;
2. verify that her rhythm was not ventricular fibrillation or pulseless ventricular tachycardia;
3. secure her airway with an endotracheal tube;
4. ensure adequate intravenous access;
5. administer 1 mg epinephrine IV push, repeating every 3-5 minutes as necessary (may substitute vasopressin for the first or second dose of epinephrine); and
6. treat any reversible causes, such as hypovolemia, hypoxia, acidosis, hyper/hypokalemia, hypothermia, drug toxicity, cardiac tamponade, tension pneumothorax, acute coronary syndrome, and pulmonary embolism.
7. During this process, I would – continue to check for a shockable rhythm (i.e. VF or VT) and, following the return of spontaneous circulation, I would –
8. initiate post-cardiac arrest care.

Clinical Notes:

• Consider utilizing echocardiography during resuscitation to:
  
  • Identify any meaningful cardiac contraction (despite being insufficient to produce a pulse)
  • Identify the development of a pericardial or pulmonary effusion
  • Identify an acute pulmonary embolism (the patient may require thrombectomy/lytic therapy)
  • Identify any regional wall motion abnormalities (the patient may require stat cardiac catheterization and/or PCI)
  • Diagnose an acute dissecting aneurysm (the patient may require emergency surgery)
  • Demonstrate that the PEA is NOT due to a correctable cause
• The return of spontaneous circulation may be determined by one of the following:
  
  • The presence of a pulse and blood pressure
  • An abrupt sustained increase in PetCO2 (usually >/= 40 mmHg)
  • The appearance of spontaneous arterial pressure waves with intra-arterial monitoring

Question 11

Post-operative Management:

With treatment, the patient experiences a return of spontaneous circulation. A member of the team suggests inducing hypothermia.

What would you do?

• (A 29-year-old 5’7” 105 kg G1P0 female presents at 34 weeks gestation to the obstetric floor following emergency transport from a small rural town.*
• HPI: The patient’s husband found her unconscious on the kitchen floor. She was taken by ambulance to the hospital where she received a loading dose of magnesium and 10 mg of Ativan. The referring hospital’s E.R. physician placed a nasal “trumpet” and had her transported to your obstetric service.*
• PMH: A family member informs you that the patient has HIV.*
• PE: Vital Signs: P = 83, BP = 148/92, R = 16, T = 37 ºC*
• Airway: Her tongue is swollen and appears to have been bitten; further visual evaluation of the oropharynx is inhibited by the large, swollen tongue.*
• CV: RRR*
• Lungs: CTA Bilaterally*
• Gen: Edema of the face and extremities noted*
• Lab: H/H = 13.1/37 Platelets = 138 urine = 3+ protein)*

Answer 11

Recognizing that therapeutic hypothermia provides protection for the brain and other organs in patients who remain comatose post-cardiac arrest, I would –

induce therapeutic hypothermia if she were unable to meaningfully respond to verbal commands after –

• treating any precipitating causes,
• optimizing ventilation and oxygenation (i.e. providing the lowest Fio2 that will maintain an arterial oxygen saturation >/= 94%, avoiding hyperventilation, and utilizing waveform capnography), and
• optimizing cardiopulmonary function (i.e. utilizing fluids, inotropes, and vasopressors to treat any systolic blood pressure < 90 mmHg and maintain a mean arterial pressure >/= 65 mmHg).

Question 12

Post-operative Management:

When is therapeutic hypothermia indicated post-cardiac arrest?

• (A 29-year-old 5’7” 105 kg G1P0 female presents at 34 weeks gestation to the obstetric floor following emergency transport from a small rural town.*
• HPI: The patient’s husband found her unconscious on the kitchen floor. She was taken by ambulance to the hospital where she received a loading dose of magnesium and 10 mg of Ativan. The referring hospital’s E.R. physician placed a nasal “trumpet” and had her transported to your obstetric service.*
• PMH: A family member informs you that the patient has HIV.*
• PE: Vital Signs: P = 83, BP = 148/92, R = 16, T = 37 ºC*
• Airway: Her tongue is swollen and appears to have been bitten; further visual evaluation of the oropharynx is inhibited by the large, swollen tongue.*
• CV: RRR*
• Lungs: CTA Bilaterally*
• Gen: Edema of the face and extremities noted*
• Lab: H/H = 13.1/37 Platelets = 138 urine = 3+ protein)*

Answer 12

Therapeutic hypothermia is indicated for any patient who is comatose following the return of spontaneous circulation after being resuscitated for –

• an out-of-hospital ventricular fibrillation cardiac arrest (Class I),
• an in-hospital cardiac arrest with any initial rhythm (Class IIb), or
• an out-of-hospital cardiac arrest where the initial rhythm was PEA (Class IIb).

Question 13

Post-operative Management:

How would you induce therapeutic hypothermia?

• (A 29-year-old 5’7” 105 kg G1P0 female presents at 34 weeks gestation to the obstetric floor following emergency transport from a small rural town.*
• HPI: The patient’s husband found her unconscious on the kitchen floor. She was taken by ambulance to the hospital where she received a loading dose of magnesium and 10 mg of Ativan. The referring hospital’s E.R. physician placed a nasal “trumpet” and had her transported to your obstetric service.*
• PMH: A family member informs you that the patient has HIV.*
• PE: Vital Signs: P = 83, BP = 148/92, R = 16, T = 37 ºC*
• Airway: Her tongue is swollen and appears to have been bitten; further visual evaluation of the oropharynx is inhibited by the large, swollen tongue.*
• CV: RRR*
• Lungs: CTA Bilaterally*
• Gen: Edema of the face and extremities noted*
• Lab: H/H = 13.1/37 Platelets = 138 urine = 3+ protein)*

Answer 13

I would utilize cooling blankets, ice packs, or the rapid infusion of 30 mL/kg ice-cold (4 ºC) LR or normal saline to reduce her temperature to 32-34 ºC (89.6-93.2 ºF).

I would then utilize an esophageal thermometer, a bladder catheter (in non-anuric patients), or a pulmonary artery catheter (if one were already being utilized for other indications) to monitor her core temperature and maintain her hypothermia for 12-24 hours.

Clinical Notes:

• No single method of inducing hypothermia has proven to be optimal.
• Axillary and oral temperatures are inadequate for monitoring core temperatures; tympanic temperature probes are often unreliable.
• Bladder temperatures in anuric patients and rectal temperatures may differ significantly from brain or core temperatures, making these methods of temperature monitoring unreliable.
• Consider using two sources for temperature measurement during induced hypothermia.