Anesthetic Management of a Parturient with Hemolysis, Elevated Liver Enzyme Levels, and Low Platelet Syndrome Complicated by Renal Insufficiency and Coagulopathy.

The objective of this study is to describe the anesthetic management of a parturient with hemolysis, elevated liver enzyme levels, and low platelet (HELLP) syndrome and renal insufficiency. A 28-year-old female patient, gestational age of 35 weeks, with hypertensive crisis (blood pressure 190/110 mmHg), was admitted for an emergency cesarean section after diagnosis of HELLP syndrome and renal insufficiency. We performed total intravenous general anesthesia with rapid sequence induction. During the surgical procedure, reduced urine output and coagulopathy were detected. After the treatments of transfusion, diuresis, and anticoagulation, the surgery finished uneventfully. The patient was taken to the Intensive Care Unit without extubation and discharged on the 6th postoperative day. This case report revealed a successful anesthetic management applied to a pregnant woman with HELLP syndrome complicated by renal insuffciency and coagulopathy. There are several case reports about HELLP syndrome, but the patient in this paper is complicated with renal insuffciency and coagulopathy which made the treatment diffcult to handle.

INTRODUCTION

HELLP syndrome which is characterized by hemolysis, elevated liver enzyme levels, and low platelet count is a severe obstetric complication which usually appears in the third trimester of pregnancy.[1] Sometimes, HELLP syndrome leads to coagulopathy or even disseminated intravascular coagulation which can make emergency surgery a serious challenge.

There are two case reports about HELLP syndrome complicated with different diseases.[23] The patient in this paper is complicated with renal insufficiency and coagulopathy which make this case report unique.

CASE REPORT

A 28-year-old woman, gravida 2 para 0 who complained of headache and persistent epigastric or right upper quadrant pain for 1 h with dizziness, blurred vision, nausea, and vomiting, was admitted to our hospital at 35 weeks and 2 days’ gestation. The patient's body weight was 67 kg and height was 161 cm. She was healthy before the pregnancy and did not undergo any regular prenatal examinations. The baby was conceived naturally. Written consent of publishing of this paper was obtained from the patient when she was discharged.

The patient was drowsy and had an anemic appearance. Physical examination revealed axillary temperature of 37.1°C, high blood pressure (BP) (190/110 mmHg) with a heart rate of 102 beat/min, and respiratory rate of 22 breath/min. Chest auscultation revealed clear breath sounds without rales. Tenderness over the right upper quadrant was noted. Bilateral lower extremity pitting edema was observed.

Laboratory tests were as follows: urine protein, 2+; urine occult blood, 3+; red blood cells, 2.68 × 1012/L; hemoglobin, 91 g/L; white blood cells, 9 × 109/L; platelets, 92 × 109/L; aspartate aminotransferase, 331.4 U/L; alanine aminotransferase, 116.1 U/L; albumin, 26.3 g/L; total bilirubin, 35.4 μmol/L; indirect bilirubin, 21.4 μmol/L; plasma urea nitrogen, 8.9 mmol/L; and creatinine, 134.1 μmol/L. HELLP syndrome was diagnosed based on the above laboratory test findings.

Computerized tomography performed showed multiple cerebral infarctions in the bilateral temporal and basal ganglia regions and a thin layer of hemorrhagic lesion in the left temporoparietal cortex. Ultrasound revealed changes in the liver parenchyma and a small amount of abdominal effusion. Fetal heart monitor showed that fetal heart rate was 106 beat/min and irregular. The decision was made to perform an emergency cesarean section to terminate pregnancy as soon as possible.

Preoperative management

The patient was treated immediately with intravenous magnesium sulfate and 5–10 μg/min nitroglycerin, sublingual 10 mg nifedipine, and intramuscular 100 mg phenobarbital sodium. Coagulation function showed prothrombin time, 12.3 s; activated partial thromboplastin time, 43.2 s; and fibrinogen, 2.6 g/L. The patient did not drink or eat for 12 h.

Anesthetic management

The patient was positioned supine with left side tilt in the operating room. American Society of Anesthesiologists grade was evaluated as III–E. A preanesthetic evaluation showed a Class II Mallampati airway with mild oral mucosa swelling. Standard monitoring (electrocardiography, pulse oximetry, and noninvasive BP) was attached to the patient. Respiratory frequency was 20 breath/min, and pulse oxygen saturation was 98%. BP was 175/102 mmHg with a heart rate of 96 beats/min.

Ringer's lactate solution was administered at a rate of 200 ml/h. After the surgical area was disinfected and sterile drapes were placed, 100 μg remifentanil and 60 mg propofol were injected slowly. When the patient lost consciousness, the operation began. Then, an injection of 100 mg succinylcholine was given for intubation. Nitroglycerin 2 μg/kg was administered for blood control. Anesthesia was maintained with infusions of propofol at a rate of 300–400 mg/h and remifentanil at a rate of 0.6 mg/h. Fentanyl and cisatracurium were administered intermittently as needed after the umbilical cord was clamped. In 3 min after the beginning of surgery, a female neonate was delivered, and then resuscitation was initiated by the neonatal team. The neonate was immediately intubated with Apgar scores of 1 and 5 at 1 and 5 min, respectively. The patient received 20 IU oxytocin by the intravenous route followed by intramuscular 250 μg carboprost tromethamine. During surgery, the patient was hemodynamically stable. Before delivery of the baby, we managed to control BP at the range of 140–160/80–100 mmHg.

Since the patient's admission, no urine output was observed; hence, after proper intravenous infusion and blood transfusion, 20 mg furosemide was administered by the intravenous route and 40 mg was repeated 20 min later. After a while, a small amount of urine flew out. Dexamethasone of 10 mg and 125 ml of 20% mannitol was given. According to the result of blood gas analysis, 150 ml of 5% sodium bicarbonate was infused.

During surgery, multiple spontaneous hemorrhagic lesions in the peritoneum were found. Blood samples were drawn and sent for laboratory tests. Blood routine showed that her platelet count, red blood cell count, and hemoglobin were reduced to 68 × 109/L, 2.00 × 1012/L, and 61 g/L, respectively. Coagulation function indicated fibrinogen, 1.8 g/L; prothrombin time, 17.4 s; activated and partial thromboplastin time, 53.2 s. On the base of the result, the diagnosis of HELLP syndrome was confirmed, and then 50 mg heparin was intravenously administered.

The operation lasted for 75 min. One unit of packed red blood cells and 1 unit of fresh frozen plasma were transfused. A total of 300 ml lactated Ringer's solution was given during the entire period in the operative room. Urine output was 40 ml.

After the surgery, the patient was transferred to the Intensive Care Unit and extubated 2 h later. A total of 1 unit of platelets and 1 unit of fresh frozen plasma was transfused in the Intensive Care Unit, according to platelet count (4.1 × 109/L), coagulation profile, and evidence of active bleeding. Subsequently, the patient's coagulation profile was normalized and platelet count increased to 146 × 109/L on the 1st postoperative day. Urine output increased gradually, and then plasma urea nitrogen and creatinine were within the normal ranges on the 3rd day after the operation. The edema gradually vanished 4 days after operation and the patient was discharged 6 days later uneventfully.

DISCUSSION

The key to the anesthetic management of such a patient is to control hypertension, to ensure oxygen supply to the fetus, to consider the presence of liver and renal dysfunctions, to prevent pulmonary edema, and to decrease bleeding tendency.[1]

General anesthesia is a good choice in this case, compared with regional anesthesia which can lead to significant time loss due to epidural puncture, risk of epidural hematoma, and hemodynamic instability from high-level blockage. Remifentanil and propofol are preferred for anesthetic induction and maintenance before delivery of the fetus because of rapid onset and short duration. Remifentanil and propofol both can cross the placenta but appear to be rapidly metabolized by both the mother and the fetus.[4] The combination of remifentanil and propofol can reduce the incidence of maternal awareness, inadequate analgesia, and hypertensive responses, following tracheal intubation and surgical incision. However, the effect of these drugs on the fetus remains controversial. Therefore, we choose to shorten the time from administration of anesthetics to delivery of the baby.

Close hemodynamic monitoring should be done during the perioperative period, especially before delivery of the baby.[56] In this case, sublingual 10 mg nifedipine is used to achieve adequate BP control in short time without overshoot hypotension.[7] According to the previous study, esmolol 1.5 mg/kg or nitroglycerin 2 μg/kg can blunt the hemodynamic changes associated with intubation and surgical procedures.[8]

In this case, the intravenous administration of fluids to improve renal perfusion is not recommended due to high risk of heart failure which is a potential complication of preeclampsia.[9] The risk of renal failure must be balanced against the risk of heart failure.

In this patient where disseminated intravascular coagulation was highly suspected, there may be benefits in using heparin for anticoagulation due to its reversibility. There is no evidence that infusion of plasma stimulates the ongoing activation of coagulation. In patients at high risk of bleeding and with a platelet count of <50 × 1012/L, transfusion of platelets should be considered.[10]

However, it should be kept in mind that regardless of the preferred anesthetic technique, complications such as eclampsia, pulmonary edema, cardiac failure, and disseminated intravascular coagulation events are still possible during postoperative period, and majority of maternal deaths occur within postpartum 1st week.[1] Therefore, this patient was transferred to the Intensive Care Unit after the operation.

CONCLUSION

We have described the successful anesthesia of a parturient with HELLP syndrome complicated by renal insufficiency and coagulopathy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.