Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942013000300011
Brazilian Journal of Anesthesiology
Clinical Information

Pesando riscos e benefícios: lições aprendidas com as intervenções terapêuticas de um caso com pré-eclâmpsia grave

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

Shiqin Xu; Xiaofeng Shen; Fuzhou Wang

Downloads: 0
Views: 1190

Resumo

JUSTIFICATIVA E OBJETIVO: A pré-eclâmpsia é uma síndrome da disfunção de múltiplos órgãos (SDMO) devido a suas manifestações típicas e atípicas que incluem hipertensão, proteinúria, síndrome HELLP, encefalopatia hipertensiva e coagulopatia. O manejo ideal desses pacientes requer uma avaliação do balanço entre os benefícios e riscos das estratégias terapêuticas, anestésicas e obstétricas. RELATO DE CASO: Paciente grávida de 35 anos, com uma gravidez anterior sem complicações, deu entrada em nosso instituto médico em caráter de emergência às 29 semanas de gravidez. A paciente apresentava-se com tontura, angústia no peito, palpitação, visão embaçada e sangramento vaginal. Após exame físico e laboratorial, a paciente foi diagnosticada com pré-eclâmpsia grave, síndrome HELLP, descolamento prematuro da placenta e SDMO. A paciente também apresentava deformidade da coluna vertebral e pélvica, fixação da articulação mandibular e deslocamento traqueal por causa de um acidente de trânsito ocorrido havia 11 anos. Portanto, uma cesariana de urgência foi feita sob anestesia geral com intubação nasotraqueal usando fio-guia. A paciente recebeu alta diretamente da unidade de terapia intensiva obstétrica no sétimo dia pós-operatório, com pressão arterial normal e recuperação completa das funções orgânicas. CONCLUSÕES: Este caso merece uma discussão mais detalhada sobre as considerações anestésicas no momento de se tomar uma decisão clínica para o tratamento de tal paciente. O bloqueio do neuroeixo é a primeira escolha para pacientes com pré-eclâmpsia submetidas à cesariana quando existe uma trombocitopenia moderada, mas não progressiva. Quando se opta pela anestesia geral, sedação e analgesia adequadas são necessárias para o bom controle da resposta do estresse à intubação, especialmente em pacientes com sinais neurológicos, e para evitar complicações cerebrais sérias.

Palavras-chave

ANESTESIA, Obstétrica, CIRURGIA, Cesárea, Insuficiência de Múltiplos Órgãos, Pré-Eclâmpsia, Síndrome HELLP

Abstract

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 7th 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.

Keywords

Pre-Eclampsia, HELLP Syndrome, Multiple Organ Failure, Anesthesia, Obstetrical, Cesarean Section

References

Poole JH. Multiorgan dysfunction in the perinatal patient. Crit Care Nurs Clin North Am. 2004;16:193-204.

Sibai B, Dekker G, Kupferminc M. Pre-eclampsia. Lancet. 2005;365:785-799.

Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol. 2009;200:e1-e7.

Koyama S, Tomimatsu T, Kanagawa T. Spinal subarachnoid hematoma following spinal anesthesia in a patient with HELLP syndrome. Int J Obstet Anesth. 2010;19:87-91.

Crosby ET, Preston R. Obstetrical anaesthesia for a parturient with preeclampsia, HELLP syndrome and acute cortical blindness. Can J Anaesth. 1998;45:452-459.

Okafor UV, Efetie ER, Igwe W, Okezie O. Anaesthetic management of patients with preeclampsia/eclampsia and perinatal outcome. J Matern Fetal Neonatal Med. 2009;22:688-692.

Gogarten W. Preeclampsia and anaesthesia. Curr Opin Anaesthesiol. 2009;22:347-351.

Richa F, Yazigi A, Nasser E, Dagher C, Antakly MC. General anesthesia with remifentanil for Cesarean section in a patient with HELLP syndrome. Acta Anaesthesiol Scand. 2005;49:418-420.

Boutonnet M, Faitot V, Katz A, Salomon L, Keita H. Mallampati class changes during pregnancy, labour, and after delivery: can these be predicted?. Br J Anaesth. 2010;104:67-70.

Joshi D, James A, Quaglia A, Westbrook RH, Heneghan MA. Liver disease in pregnancy. Lancet. 2010;375:594-605.

Marik PE. Hypertensive disorders of pregnancy. Postgrad Med. 2009;121:69-76.

Martin JN Jr, Rose CH, Briery CM. Understanding and managing HELLP syndrome: the integral role of aggressive glucocorticoids for mother and child. Am J Obstet Gynecol. 2006;195:914-934.

Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol. 2004;103:981-991.

Celik C, Gezginc K, Altintepe L. Results of the pregnancies with HELLP syndrome. Ren Fail. 2003;25:613-618.

Ertan AK, Wagner S, Hendrik HJ, Tanriverdi HA, Schmidt W. Clinical and biophysical aspects of HELLP-syndrome. J Perinat Med. 2002;30:483-489.

Magann EF, Martin JN Jr. Twelve steps to optimal management of HELLP syndrome. Clin Obstet Gynecol. 1999;42:532-550.

Audibert F, Friedman SA, Frangieh AY, Sibai BM. Clinical utility of strict diagnostic criteria for the HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Am J Obstet Gynecol. 1996;175:460-464.

Sibai BM. The HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): much ado about nothing?. Am J Obstet Gynecol. 1990;162:311-316.

Habli M, Eftekhari N, Wiebracht E, Bombrys A, Khabbaz M, How H, Sibai B. Long-term maternal and subsequent pregnancy outcomes 5 years after hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. Am J Obstet Gynecol. 2009;201:e1-e5.

Pokharel SM, Chattopadhyay SK, Jaiswal R, Shakya P. HELLP syndrome-a pregnancy disorder with poor prognosis. Nepal Med Coll J. 2008;10:260-263.

Vigil-De Gracia P. Maternal deaths due to eclampsia and HELLP syndrome. Int J Gynaecol Obstet. 2009;104:90-94.

Levy DM. Emergency Caesarean section: best practice. Anaesthesia. 2006;61:786-791.

Davies GA, Maxwell C, McLeod L. Obesity in pregnancy. J Obstet Gynaecol Can. 2010;32:165-173.

Petrini F, Accorsi A, Adrario E. Recommendations for airway control and difficult airway management. Minerva Anestesiol. 2005;71:617-657.

Task Force on Management of the Difficult Airway: Practice guidelines for management of the difficult airway - An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98:1269-1277.

Martin JN Jr, Files JC, Blake PG, Perry KG Jr, Morrison JC, Norman PH. Postpartum plasma exchange for atypical preeclampsia-eclampsia as HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Am J Obstet Gynecol. 1995;172:1107-1127.

Martin JN Jr, Perry KG Jr, Roberts WE. Plasma exchange for preeclampsia: III. Immediate peripartal utilization for selected patients with HELLP syndrome. J Clin Apher. 1994;9:162-165.

Galloway S, Lyons G. Preeclampsia complicated by placental abruption, HELLP, coagulopathy and renal failure-further lessons. Int J Obstet Anesth. 2003;12:35-39.

5dd423f30e88251211c63493 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections