Advances in Clinical and Medical Research Anesthetic management in Impending Eclampsia with Intracranial Pathology

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.


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.

include trauma, ja
ndice, 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

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 destress and Right sided de-compressive emergency craniotomy was done later [1,2].

lower segm
nt cesarean section was done in view of fetal destress and Right sided de-compressive emergency craniotomy was done later [1,2].


On examination

• Patient was irritable


Management

• Difficult airway cart and emergency drugs were kept ready , informed valid written consent , high risk consent were taken.Premedication with Inj.Glycopyrr

On examination
• Patient was irritable

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 .

d
ecuronium.• 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 .emergencyneurologist 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 compl • After completion of surgery patient was extubated shifted to SICU.

•
Later on next morning patient became drowsy again .emergencyneurologist 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 .
tion of surgery patient was shifted

sicu a
d 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 intrace • Both mother and baby are healthy.

bral hematoma (80*
2mm), Effacement of ipsilateral right lateral ventricle, midline shift of approx.1.2cm towards left suggestive of falcine herniation (Figure 1).


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

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.

the left a
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, Hyp

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