DP20: POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME (PRES) IN PREGNANCY: A CASE REPORT AND ANESTHETIC MANAGEMENT DURING PRETERM CESAREAN DELIVERY
Meena Kanhai, MD; Laurie Davies, MD; Pavel Balduyeu, MD
University of Florida
Introduction/Background: Posterior Reversible Encephalopathy Syndrome (PRES) is a rare neurological condition that is characterized by reversible swelling in the posterior regions of the brain on imaging with clinical signs of headache, seizures, confusion, visual disturbances, and neurological deficits. We present a case of a parturient who developed PRES with associated seizure and was subsequently managed with emergent Cesarean delivery and the anesthetic management during this case.
Methods: An 18 year old primigravida at 30 weeks and 5 days was transferred to our tertiary care center after a seizure at home. Past medical history included obesity, childhood asthma, marijuana use, vaping (last within hours of presentation), and testing positive for influenza and norovirus. Upon admission, the patient reported fatigue, mild headache, with tongue pain and swelling from biting during the seizure. Further neuroimaging with CT and MRI confirmed the diagnosis of PRES. Initial non-contrast CT head showed hypodensities in the right parietal, left parietal, and left frontal lobes, with possible underlying mass. Magnesium sulfate infusion was initiated and as needed labetalol was given to treat elevated blood pressures. The decision was made to proceed with emergent Cesarean section with delivery as the treatment for PRES.
Results: A discussion was had with the patient and surgical team, and the decision to proceed with neuraxial anesthesia was made. Labs returned with an appropriate platelet level for proceeding with neuraxial anesthesia. The patient was promptly brought to the operating room. Video laryngoscopy was available in the room if needed to convert to general anesthesia. The patient was positioned sitting, ASA monitors placed, and back prepped with chlorhexidine. After 1% lidocaine was injected at the skin, a standard introducer was placed at the L3-4 level followed by a 25G Whitacre needle with return flow of clear CSF. An injection of 12 mg bupivacaine, 100 mcg morphine, and 20 mcg of fentanyl was injected without resistance and a T4 level block was achieved. Phenylephrine infusion was titrated to keep blood pressure within 20% of her presenting baseline and Magnesium infusion continued. The operation and delivery proceeded without anesthetic or surgical complication and the patient was transferred to the PACU.
Discussion/Conclusion: This case highlights the importance of considering additional causes of seizures during pregnancy in addition to eclampsia. PRES is a condition that with swift treatment of the cause, in this case pregnancy, can lead to resolution and prevent permanent damage.
The use of a multidisciplinary approach to the anesthetic management of these patients is also vital. Neuraxial anesthesia, when not contraindicated, offers several advantages if time allows, even in emergent settings. In the case of our patient, we expected difficulties with both airway management and ventilation with her tongue swelling and smoking history with superimposed Influenza virus. The sympathectomy associated with spinal anesthesia and avoidance of stimulation with laryngoscopy were preferred to avoid worsening hypertension and cerebral edema. However, anesthesiologists must be prepared for all contingencies, including emergent conversion to general anesthesia with an expected difficult airway.