MANAGEMENT OF ANESTHESIA IN AN IMPENDING ECLAMPSIA PARTURIENT

WITH MULTIFORM GLIOBASTOMES

UNDERGO AN EMERGENCY SECTIO CAESAREAN, A CASE REPORT
Khairunnisai*, Buyung H.**, Isngadi**
Departemen Anestesiologi dan Terapi Intensif
Fakultas Kedokteran Universitas Brawijaya RS dr Saiful Anwar Malang, Jawa Timur

Abstract
Background
The incidence of brain tumour in pregnant women is not known, non-obstetric
surgery during pregnancy is 0.75-2%, and incidence of intracranial neoplasm in 25-34
years aged parturients is reported as 6.9/100,000. Intracranial neoplasms are rare
during pregnancy, meningioma is the most common whereas glioma is even rarer .
Surgery for a delivery in a impending eclampsia parturient with an intracranial tumor
without a definitive surgery for the intracranial lession is even rarer and can be quite
challenging and difficult for the anesthetist as it requires a fine balance of both maternal
and fetal safety, and neuroprotection brain, too.
Purpose
Describe how the management of anesthesia in impending eclampsia parturient
with glioblastom multiform that undergo emergency sectio caesarean .
Case Report
An very rare case, female 40 years old have 30-32 weeks amenorhea with
emergency obstetrical condition i.e severe pre-eclampsia and symptoms of impending
eclampsia. Increased intracranial pressure symptoms such nausea, vomiting, and
blurred of vision ar founded. A hystory of gliobastome (GBM) multiformed and eclampsia
seizure at the 3rd pregnancy since one years ago with a poor obedient phenytoin drug
therapy. A CT scan imaging was performed and showed a glioblastomes (GBM) multiform
at parietal lobe dextra with vasogenik oedem. Neurological deficits in form right
hemiestesia, right quadrinopsia, and gravidarum polyneuropathy. Hypertension is
untreat since second month of pregnancy with blood pressure range 150-170/90-100
mmHg without therapy. Proteinuri qualitative +3 was detected from urinalyzed. Nifedipin
and Magnesium sulphate (MgSO4) was giving in emergency room.

Picture 1. A head CT scan imaging showed the glioblastome multiform at dextra

parietal lobe with vasogenic edem. Left is the first picture ( 2013 ) and the right is
the newest picture ( 2014 ). There are no significantly change

Routine pre-operative preparation was performed with corticosteroid to reduce

cerebral edem. Premedication aspiration prophylaxis with ranitidine and metoclopramide,
one a half hours before induction anesthesia beginning. A head up and left table tilt
was perform, followed preoxygenation and a rapid sequence induction with propofol,
phentanyl, vecuronium and administered lidocaine and paratracheal block are given to
facilitated intubation. A smooth intubation was done and a female baby, weight 1620
gram was born after 8 minute induction delivery time and 3 minute uterine incision time
with the apgar score 1-3-5-7 without active resucitated. Adjuvant midazolam and
morphine was given after delivery of the baby. Maintanance anesthesia with oxygen and
sevoflurane was facilitate 30 minute procedur with 300 ml bleedig. Hemodynamics
during surgery was stabiled, and after surgery the mother under controlled ventilation in
intensive care unit for 6 hours under midazolam as sedation and analgesia phentanyl by
syringe pump. Extubation was doing after assessment of neurologic and hemodynamic
status stabiled, facilitated with lidocaine. The patient discharged 3 days after surgery and
will have a schedule to elective neurosurgery.
Discussion :
This patient 40 y.o included in the range of age evidence intracranial neoplasm
in parturient and preeclampsia-eclampsia too 1,2,3 , but gliobalstoma case is very rare at
the pregnant 4. The management of such a case requires multidisciplinary approach 2,4,5 ;
neurosurgery, obstetric, anesthetist and pediatric are the team. So many consideration to
management this case but the clinical goals of this case. Traditionally, spinal anesthesia
is the preferred technique of choice for a cesarean section 1,5 but in this case general
anesthesia was indicated since she had raised ICP. The goal of anesthetic should ensure
overall maternal and fetal wellbeing, forestall fluctuations in ICP and maintain
hemodynamic stability. At the same time,a sufficient depth of anes thesia and a rapid
recovery are essential. Aspiration prophylaxis, pre-oxygenation, and vigilant monitoring
are desirable too.2,3,4,6
We achieved thats goal by balance anesthesia with intravena and volatile
agents. Etomidate and thiopenthal are mentioned the best for neurosurgery and pregnant
but not available in our institution, so induction with propofol 40 mg combined sevoflurane
1 vol% are choice. Opioids were omitted as neonatal respiratory depression, apnea and
chest wall rigidity are known1,7 but we havent a short acting opioids such as remifentanil
and alfentanil at our institution and so phentanyl 50 mcg make a less decreased
hemodynamics but level of sedation and analgesia was achieved. An lidocaine
intravenous and paratracheal block was performed to blunting stress respons due to
laryngoscopic and intubation procedure. Vecuronium 6 mg to facilitated intubation,
without fluctuation of hemodynamics.7 Post operative pain was covered by phentanyl
continue by syringe pump combined with paracetamol 1 gr intravenous q6h. A PONV
medication with metoclopramide, ondancentron and dexamethasone was schedule in
ICU.4,7,8
Extubation was doing after 6 hours operative with stability of neurological and
hemodynamics assessment, no pain and vomiting complaint from her. Finally she had a
hospital discharged from porturition wall at the 3 rd day and then will have schedule to
elective neurosurgery.
Conclusion :
The anesthetic management of sectio caesarean for the impending eclampsia
pregnant patient with a diagnosed intracranial tumour must be challenging and difficult.
This requires close communication between the neurosurgeon, obstetrician,pediatric and

anesthesiologist in order to ensure that all consultants appreciate the inherent risks and
to permit the anesthesiologist to plan the anesthetic appropriately. Both general
anesthesia and regional analgesia/anesthesia have been described with variable
outcomes. In order to ensure overall maternal and fetal safety, the anesthetic technique
chosen should avoid fluctuations in intracranial pressure (ICP), maintain a brain
neuroprotection , maintain a stable hemodynamics and provide a sufficient depth of
anesthesia and analgesia. We report the succesful use of general anesthesi, combined
with multimodal balanced analgesia for the management of a impending eclampsia
patient with a glioblastome tumour.
Key words : management
glioblastome

anesthesia, impending eclampsia, sectio caesarean,

References
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