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2008 Taiwan Society of Anesthesiologists

CASE REPORT

Acta Anaesthesiol Taiwan 2008;46(1):4648

*Corresponding author. Department of Anesthesiology, Tri-Service General Hospital, 325, Section 2, Cheng-Gong Road,

Nei-Hu District, Taipei 114, Taiwan, R.O.C.

E-mail: linjozo@yahoo.com.tw

Eclampsia Following Cesarean Section with

HELLP Syndrome and Multiple Organ Failure

Shun-Ming Chan1, Chih-Cherng Lu1, Shung-Tai Ho1, Wen-Jinn Liaw1,Chen-Hwan Cherng1, Wei-Hwa Chen2, Tso-Chou Lin1*

1Department of Anesthesiology, Tri-Service General Hospital, School of Medicine, National Defense

Medical Center, Taipei, Taiwan, R.O.C.2Department of Gynecology and Obstetrics, Tri-Service General Hospital, School of Medicine,

National Defense Medical Center, Taipei, Taiwan, R.O.C.

Received: Oct 12, 2007

Revised: Dec 11, 2007

Accepted: Dec 14, 2007

KEY WORDS:

eclampsia;

HELLP syndrome;

multiple organ failure;

postpartum period

We present a rare case of postpartum eclampsia with overt acute heart and renal

failure, in the absence of any precursive signs of preeclampsia. A 41-year-old par-

turient underwent elective cesarean section for the delivery of twins under spinal

anesthesia. Prior to the procedure, preoperative laboratory examination revealed

only traceable proteinuria but she had hypertension perioperatively. Approximately

8 hours after the cesarean section, she developed seizures, followed by evident

acute heart and renal failure. The diagnosis of postpartum eclampsia with HELLP

(hemolysis, elevated liver enzymes and low platelets) syndrome was established

and she was admitted to the surgical intensive care unit for close care. Fortunately,

the patient recovered fully and was discharged 26 days later. From this illustrativeexample, unexplainable and sustained hypertension following cesarean section should

serve as a signal to warn the health care staff concerned about the possibility of

impending life-threatening postpartum eclampsia.

1. Introduction

Hypertensive disease occurs in approximately 1222%

of pregnancies, and it is directly responsible for

17.6% of maternal deaths in the United States.1

Eclampsia, characterized by preeclamptic signs with

a seizure, is a serious and unpredictable accompa-

niment to pregnancy-induced hypertensive disor-

ders. Postpartum eclampsia usually happens during

the first 48 hours after delivery, but in some cases,

it may occur up to 16 days after delivery.2 HELLP

syndrome is a rare obstetric problem characterized

by hemolysis, elevated liver enzymes, and low plate-

let counts.3 Severe preeclampsia, associated with

HELLP syndrome, can occur after a normal delivery

in a parturient whose blood pressure has remained

normal throughout the antenatal period.4 This case

report illustrates a consequence of eclampsia asso-

ciated with epigastric pain and unexplainable hy-

pertension in a parturient after a normal pregnancy

and delivery.

2. Case Report

A 41-year-old woman, height 161 cm and body weight

64 kg, was admitted for labor at 38 weeks of gesta-

tion, and cesarean section was indicated because

of twin pregnancy with malpresentation. Her preg-

nancy was uneventful and her blood pressure was

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Postpartum eclampsia and multiple organ failure 47

essentially normal. Routine urine analyses had shown

a trace of protein at 32 and 38 weeks of gestation,

but was otherwise normal. Preoperative laboratory

examinations were unremarkable, i.e., hemoglobin,

11.9 g/dL; platelet count, 142109/L; blood urea

nitrogen (BUN)/creatinine, 14/0.6 g/dL; aspartate

aminotransferase (AST)/alanine aminotransferase

(ALT), 25/33 U/L and a normal coagulation profile.

After intravenous hydration with Ringers solution

1000 mL, spinal anesthesia was induced with 10 mg

of 0.5% hyperbaric bupivacaine via the L34 inter-

space, which initially achieved sensory blockade

up to the T8 level without cardiovascular com-

promise. Both twins were delivered uneventfully

and blood pressure and heart rate remained around

140/90 mmHg and 70 beats/min. However, epigas-

tric pain developed while the placenta was removed.

Ketamine 50 mg was administered intravenously

and the patients blood pressure increased to 180/

110 mmHg. Intermittent intravenous infusion of

nitroglycerin was prescribed to bring her bloodpressure down to 150/90 mmHg. The operation was

completed uneventfully and she was returned to

the ward with full consciousness, but she needed

sublingual nifedipine to control blood pressure

under 150/100 mmHg. Eight hours later, she suf-

fered from shortness of breath and a generalized

seizure, and loss of consciousness and hypotension

(70/40 mmHg) immediately followed. Emergency

resuscitation including endotracheal intubation,

intravenous magnesium sulfate, epinephrine, and

continuous infusion of dopamine was performed,

which kept her vital signs stable (blood pressure,110/70 mmHg; heart rate, 106/min). She was trans-

ferred to our surgical intensive care unit for fur-

ther investigation and management. The diagnosis

of HELLP syndrome was established, as evidenced

by the presence of anemia (hemoglobin concentra-

tion, 8.9 g/dL) and thrombocytopenia (platelet

counts, 44109/L), along with markedly elevated

liver enzymes (AST, 1531 U/L; ALT, 1154 U/L). Dexa-

methasone 5 mg intravenously twice daily was then

given for the next 3 days. Meanwhile, acute renal

failure (

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48 S.M. Chan et al

effects. It stimulates the cardiovascular system, usu-

ally resulting in increases in blood pressure, heart

rate, and cardiac output,13 and it should be used

with exceptional caution in patients with known

preeclampsia. However, there is no available report

on ketamine-induced preeclampsia or eclampsia.

In this case, we had only administered ketamine

50 mg (