Authors: Bita Badehnoosh, Mahya Khoddami-Khosroshahi, Banafsheh Mashak, Zatollah Asemi
Categories: Case Report, case report, general anesthesia, preeclampsia, pulmonary edema, spinal anesthesia
Source: Annals of Medicine and Surgery
Authors: Bita Badehnoosh, Mahya Khoddami-Khosroshahi, Banafsheh Mashak, Zatollah Asemi
Severe preeclampsia is a significant cause of maternal and neonatal morbidity and mortality. The choice of anesthesia technique in such cases is particularly challenging, as both general anesthesia (GA) and regional anesthesia (RA) have their own advantages and limitations.
A 28-year-old primigravida Iranian woman with a twin pregnancy at 30 weeks and 3 days of gestation, with a history of diet-controlled gestational diabetes, a body mass index of 35 kg/m^2^, and a history of upper respiratory tract infection approximately 4 weeks’ prior, presented to the emergency department at 30 PM with complaints of hypertension and epigastric discomfort. Her blood pressure was recorded at 160/110 mmHg. The anesthesiologist confirmed that the pulmonary edema was of non-cardiac origin. After treatment of the pulmonary edema and stabilization of the patient’s hemodynamic status, spinal anesthesia (SA) was performed using 0.5% hyperbaric bupivacaine (Marcaine), leading to the successful delivery of two male infants.
The decision to perform SA, despite the initial presence of acute respiratory distress, was made after rapid and effective hemodynamic and pulmonary stabilization. This approach reflects a deliberate risk-benefit analysis in favor of RA, given its advantages – such as reduced airway-related complications, decreased fetal drug exposure, and a lower risk of cardiovascular events during laryngoscopy – when compared to GA.
In individuals presenting with severe preeclampsia and non-cardiac pulmonary edema, SA may be judiciously administered by a proficient anesthesiologist once hemodynamic parameters and oxygenation are adequately managed with emergency pharmacological interventions.
Preeclampsia is clinically characterized by the presence of hypertension and proteinuria, which may occur with or without pathological edema, manifesting after 20 weeks of gestation, although it may also present within 4–6 weeks following parturition^[1]^. Severe manifestations of preeclampsia encompass any of the following a systolic blood pressure measuring 160 mmHg or above, or a diastolic blood pressure measuring 110 mmHg or above on at least two separate occasions, with a minimum interval of 4 hours between readings, provided that the patient is at rest (unless antihypertensive treatment has been initiated before this interval). Thrombocytopenia is defined as a platelet count falling below 100 000/µL. Furthermore, there exists an impairment of hepatic function, as evidenced by abnormally elevated serum concentrations of liver enzymes (to levels at least double the normal range), severe and persistent pain in the epigastric region unresponsive to pharmacological treatment, and not attributable to alternative diagnoses, or the presence of both conditions. Other clinical manifestations encompass progressive renal insufficiency, considered by creatinine levels above 1.1 mg/dL or a twofold elevation in creatinine levels in the absence of other renal pathologies, as well as pulmonary edema and newly emerged cerebral or visual anomalies^[1]^.HIGHLIGHTSPreeclampsia is clinically defined by hypertension and proteinuria.A 28-year-old primigravida woman presented to the emergency department.Spinal anesthesia may be safely performed with emergency drug therapy.
Preeclampsia, when complicated by pulmonary edema, is responsible for as much as 50% of maternal fatalities associated with this condition. The etiology of pulmonary edema in the context of preeclampsia is most likely attributable to a confluence of heightened hydrostatic pressure resulting from left ventricular diastolic dysfunction, elevated afterload, capillary permeability, and interstitial edema. A fundamental component of management is the rigorous control of blood pressure to mitigate afterload. There exists a paucity of studies evaluating whether blood pressure readings at initial presentation or during early gestation may serve as a predictive indicator for the onset of pulmonary edema^[2]^. The selection of anesthetic methodologies for cesarean delivery is contingent upon numerous variables, including the patient’s physiological status, the practitioner’s level of expertise, the accessibility of pharmaceuticals, and the availability of necessary equipment, among other considerations. Nonetheless, the technique ultimately selected is predicated upon its safety profile and the resultant advantages for both the mother and the fetus^[3]^. Regional anesthesia (RA), particularly spinal anesthesia (SA), has been predominantly regarded as the optimal choice for elective, uncomplicated cesarean deliveries due to its avoidance of airway manipulation, reduced risk of aspiration of gastric contents, lower risk of cardiovascular events during laryngoscopy, and relative ease of administration. While RA is widely recognized for its safety and effectiveness, it is not without potential complications. These may include sympathetic blockade leading to more challenging hemodynamic control, as well as reduced lung volumes and inadequate ventilation during cesarean delivery. Nevertheless, general anesthesia (GA) continues to be utilized, particularly in instances where RA is contraindicated or not successful. The benefits associated with GA encompass the maintenance of a patent airway, controlled ventilation, and a diminished impact on cardiovascular stability. Complications, including unsuccessful intubation, inadequate ventilation, aspiration of gastric contents, intraoperative awareness, discomfort, and fetal distress, are frequently encountered in GA^[3]^. Both SA and GA may be appropriately utilized for cesarean delivery in patients suffering from severe preeclampsia. This case is noteworthy due to the successful use of SA following rapid respiratory and hemodynamic stabilization in a patient with severe preeclampsia complicated by acute pulmonary edema (APE). Such an approach has been rarely reported in the literature, particularly in low- and middle-income countries, where GA may pose additional risks due to limited availability of airway equipment, anesthetic resources, and medications.
This case report has been reported in line with the Surgical CAse REport (SCARE) 2025 criteria^[4]^.
A 28-year-old primigravida Iranian female with a twin gestation at 30 weeks and 3 days of gestation (validated via nuchal translucency ultrasonography) presented to the emergency department at 30 PM exhibiting hypertension and epigastric discomfort. She had a pre-existing diagnosis of gestational diabetes, which was managed through dietary interventions. The patient had no history of any specific illness or surgery. She was not taking any other medication except for pregnancy supplements. She presented with a reported history of upper respiratory tract infection approximately 4 weeks ago.
Her body mass index was recorded at 35 kg/m^2^. Upon initial evaluation, the patient was found to be alert and oriented to person, place, and time. Examination of cranial nerves yielded normal results, and motor as well as sensory functions in all extremities were preserved. Auscultation of the chest revealed an absence of adventitious sounds. Cardiac examination demonstrated normal S1 and S2 heart sounds, with no murmurs or additional sounds. Notably, there was 3+ peripheral edema. Examination of the abdomen indicated no tenderness or masses. Vital signs upon admission were documented as oral 37°C; heart 90 beats per minute; blood 160/110 mmHg; respiratory 26 breaths per minute; and oxygen 95% in ambient air.
The mucous membranes were noted to be moist and exhibited a normal appearance. A recent anomaly scan indicated the presence of a monochorionic diamniotic twin gestation. The first fetus (male) was observed to be in a breech position and mild polyhydramnios. The second fetus (male) also presented in a breech position and severe oligohydramnios, which is indicative of potential early fetal growth restriction. A significant 34% discrepancy in weight between the twins was recorded, leading to a diagnosis of twin-to-twin transfusion syndrome.
Due to a recorded blood pressure of 160/110 mmHg, the patient was administered an intravenous loading dose of 4 g of magnesium sulfate, subsequently followed by a continuous infusion at the rate of 1 g/h. Additionally, she received a single intravenous (IV) labetalol at a dosage of 20 mg (based on national protocol). Nevertheless, the blood pressure continued to remain elevated (160/102 mmHg), necessitating the administration of IV labetalol at a dosage of 40 mg at 00 PM. The patient’s epigastric pain continued to be a concern. Consequently, a consultation with a cardiology specialist was requested to facilitate further management of blood pressure. In spite of the administration of additional doses of labetalol (80 mg at 30, 30, and 15 PM), the patient’s blood pressure persisted at elevated levels (reaching 160/110 mmHg; Table 1).Table 1Chronological summary of patient management and outcomesTimeEventAdmission (5:30 PM)Patient presented with hypertension (160/110 mmHg) and epigastric discomfort5:45 PMIV magnesium sulfate and labetalol initiated for blood pressure control6:00–9:15 PMMultiple doses of labetalol administered due to persistent hypertension9:30 PMTransferred to the operating room; reported dyspnea, orthopnea; and pulmonary edema diagnosed9:30–11:30 PMTreated with diuretics (furosemide) and oxygen; hemodynamic and respiratory stabilization11:50 PMEmergency cesarean section performed under spinal anesthesiaIntraoperativeDelivery of two male neonates; both required C-Reactive Protein (CRP) and intubation; transferred to neonatal intensive care unitPostoperativePatient monitored in recovery and intensive care unit; magnesium sulfate infusion for 24 hours72 hours postoperativePatient discharged in stable conditionDay 1 neonateOne of twins died due to respiratory failureDay 31 neonateThe surviving twin discharged in good health
Laboratory analyses yielded the following WBC: 13 500/μL; 10.8 g/dL; 148 000/μL; urine 3+; Na: 138 mEq/L; K: 4.7 mEq/L; Cr: 1.2 mg/dL; Fibrinogen: 320 mg/dL; Serum glutamic oxaloacetic transaminase (SGOT): 28 U/L; Serum glutamate pyruvate transaminase (SGPT): 11 U/L; alkaline phosphatase (ALP): 230 U/L; Lactate dehydrogenase (LDH): 672 U/L; total 0.3 mg/dL; direct 0.1 mg/dL.
Due to persistently elevated blood pressure unresponsive to maximal antihypertensive treatment and ongoing epigastric pain, the decision was made to terminate the pregnancy. Given the preterm twin gestation and breech presentation, an emergency cesarean section was indicated.
At 30 PM, the patient was transported to the operating room. She reported experiencing dyspnea and was unable to assume a supine position (orthopnea). She exhibited signs of cyanosis.
Vital signs upon entering the operating room were as follows respiratory 40 breaths per minute; heart 120 bpm; Blood 220/130 mmHg; and O2 84–85%
Upon auscultation, the presence of pulmonary rales was detected, leading the anesthesiologist to conclude a diagnosis of pulmonary edema. The subject presented with a reported history of upper respiratory tract infection approximately 4 weeks prior, prompting the administration of 200 mg of hydrocortisone. Furthermore, before the cardiology consultation, 40 mg of furosemide was administered.
Echocardiography conducted in the operating room ejection 50% and mild-to-moderate mitral regurgitation without evidence of pulmonary hypertension.
A non-cardiac etiology of the pulmonary edema was ascertained. The anesthesiologist proceeded to administer three doses of 40 mg furosemide at 10-minute intervals while closely monitoring blood pressure and urine output. The patient was positioned in a semi-sitting posture and received supplemental oxygen via a face mask at a flow rate of 6 L/min.
Following the initiation of diuretic therapy, the urine output exhibited an increase from 500 cc to 1400 cc, alongside an enhancement in O2 saturation from 84 to 96% while on ambient air. Upon achieving stabilization, the patient’s vital signs were documented as blood 150/80 mmHg; heart 85 bpm; respiratory 25 bpm; and auscultation of the lungs revealed clear sounds.
Since the patient exhibited no respiratory symptoms upon admission and the diagnosis of pulmonary edema was made preoperative before the cesarean section, a chest X-ray was not performed. Instead, an urgent echocardiogram was conducted in the operating room; however, imaging files are not available for attachment.
In light of the patient’s diagnosis of severe preeclampsia, the presence of a potentially challenging airway, and her subsequent improvement in condition, the anesthesiologist made the clinical decision to proceed with SA. A spinal block was executed at the L4–L5 intervertebral space utilizing 10 mg of 0.5% heavy Marcaine administered via a 25-gauge spinal needle. At 50 PM, an emergency cesarean section was conducted under SA, resulting in the delivery of two male neonates. The first neonate presented in a cephalic position with an Apgar score of 7/8, while the second was delivered in a breech position, presenting an Apgar score of 6/8 and had clubfoot and oligohydramnios. The birth weights of the neonates were recorded at 1500 g and 1000 g, respectively. Both neonates underwent cardiopulmonary resuscitation and were intubated in the operating room before being transferred to the neonatal intensive care unit.
During the surgical procedure, a total of 1500 cc of Ringer’s solution and 30 units of oxytocin were administered. The blood pressure exhibited variability, ranging from 120/70 to 150/85 mmHg. Oxygen saturation consistently remained within the range of 98–100%. The patient was subsequently transitioned to the recovery unit in satisfactory general condition. The entire anesthesia process – from the patient’s admission to the operating room and treatment of APE, through anesthesia management and monitoring in the recovery room – was conducted by a single anesthesiologist together with a nurse anesthetist.
Vital signs recorded in the recovery room respiratory 26 bpm; heart 90 bpm; blood 130/80 mmHg; oxygen 100%; and urine 300 cc.
After 30 minutes, the patient was transferred to the intensive care unit, where she was administered magnesium sulfate for a period of 24 hours. Upon conclusion of this treatment, she was relocated to the post-cesarean ward, where her blood pressure was maintained within the range of 115/70–120/75 mmHg without the necessity of pharmacological intervention. The patient was ultimately discharged in a state of satisfactory general condition 72 hours following the surgical intervention. Regrettably, one of the infants (the second twin weighed 1000 grams at birth) succumbed after 1 day as a result of respiratory failure, prematurity, low birth weight, and pulmonary immaturity. Conversely, the surviving infant was discharged from the hospital in a state of good health after 31 days (Table 1).
One week subsequent to the initial procedure, a follow-up consultation with a gynecologist corroborated the stability of the patient’s blood pressure and the absence of any postoperative complications.
The expertise and credentials of the anesthesia team engaged in the intervention have been incorporated to elucidate the framework surrounding clinical decision-making processes. An unequivocal ethical declaration, along with the verification of informed written consent, was obtained from the patient.
APE associated with preeclampsia is clinically defined as acute respiratory distress that may arise during pregnancy or within the initial 45 days postpartum, with a higher incidence observed prior to delivery as opposed to post-delivery. This condition is characterized by an abrupt onset of dyspnea, the presence of moist crackles upon auscultation, oxygen desaturation, and radiographic findings consistent with pulmonary edema. The pathophysiological mechanisms that contribute to the onset of APE in the context of preeclampsia are attributed to an elevation in cardiac output or plasma volume, coupled with a reduction in plasma colloid osmolality or osmolarity during the course of pregnancy^[5]^.
Moreover, there is a notable escalation in both peripheral vascular resistance and peripheral vascular permeability in individuals with preeclampsia, which consequently leads to an increase in afterload. The diagnosis of APE necessitates the utilization of echocardiography, which subsequently facilitates the distinction between noncardiogenic and cardiogenic etiologies. In cases of noncardiogenic APE, echocardiographic findings typically do not demonstrate any significant abnormalities, with preeclampsia frequently identified as the underlying cause^[5]^.
The advantages of RA concerning maternal and fetal outcomes are markedly superior to those associated with GA. Despite the ongoing discourse regarding the optimal anesthetic strategy for lower uterine cesarean sections in patients with severe preeclampsia and eclampsia, SA is deemed to be more effective than GA. Although SA carries a potential risk of hypotension, it remains the preferred choice primarily to reduce the risks associated with GA. These risks include hypertension induced by laryngoscopy during intubation and extubation, difficulties with intubation such as failed or esophageal intubation, pulmonary aspiration, risk of cerebral hemorrhage, interactions between magnesium sulfate and non-depolarizing muscle relaxants, delayed recovery or complications related to reversal agents, and various drug-related concerns. Additionally, GA increases the likelihood of uterine atony and hemorrhage, greater fetal exposure to inhalational anesthetics and muscle relaxants, and neonatal hypotonia.
The prominent adverse effects associated with SA include hypotension, a reduction in cardiac output, which leads to placental hypoperfusion, suboptimal perinatal outcomes, as well as the potential for iatrogenic pulmonary edema resulting from the administration of intravenous fluid boluses in the management of spinal-induced hypotension. However, the hypotensive consequences are generally diminished in individuals experiencing severe preeclampsia when compared to both healthy pregnant and non-pregnant females, a phenomenon that may be attributed to elevated levels of catecholamines and sustained vasoconstriction, which stem from a disruption in the balance of pro- and antiangiogenic growth factors, subsequently causing damage to the vascular epithelium^[6]^. In this case, due to severe preeclampsia, epigastric pain, and treatment-resistant severe hypertension, the decision was made to terminate the pregnancy. Given the preterm twin gestation and breech presentation, an emergency cesarean section was indicated.
Because of APE, rapid treatment of respiratory distress and stabilization of the patient’s hemodynamic status before the anesthesia technique was prioritized in the operating room.
A case report by Tavianto et al^[7]^ described a 31-year-old primigravida diagnosed with preeclampsia complicated by pulmonary edema and peripartum cardiomyopathy. The patient was scheduled for an emergency cesarean section under GA. Alves et al^[8]^ reported that a pregnant woman at 36 weeks of gestation with preeclampsia complicated by pulmonary edema required an urgent cesarean delivery. The procedure was successfully performed under epidural anesthesia. Also, in a case report by Tao et al^[9]^, a pregnant woman at 25 weeks of gestation with severe preeclampsia complicated by pulmonary edema required an emergency cesarean section. Due to contraindications for neuraxial anesthesia, the procedure was performed under GA. Moreover, Hashey et al^[10]^ reported the case of a 37-year-old pregnant woman at 29 weeks of gestation, presenting with severe preeclampsia complicated by pulmonary edema. The on-call anesthesiologist elected to perform SA, as the patient was able to maintain a supine position while receiving oxygen through a non-rebreathing mask, thereby avoiding the hypertensive response typically associated with endotracheal intubation.
This case report highlights the successful use of SA following rapid stabilization of pulmonary edema in a patient with severe preeclampsia, a clinical scenario with limited documentation, especially in low- and middle-income settings. The detailed clinical management, including close hemodynamic monitoring and multidisciplinary collaboration, underscores the feasibility and safety of RA in high-risk obstetric patients after adequate stabilization. However, limitations include the single-case design, which limits generalizability, and the absence of imaging attachments such as chest X-ray and echocardiography images. Additionally, long-term maternal and neonatal follow-up data beyond the initial hospitalization period are not available.
Rapid identification and treatment of pulmonary edema are critical in managing severe preeclampsia to improve maternal and fetal outcomes.SA can be safely administered in severe preeclampsia patients with pulmonary edema once hemodynamic and respiratory parameters are stabilized.Multidisciplinary collaboration and continuous monitoring are essential to navigate the complex anesthetic challenges and minimize maternal and neonatal morbidity and mortality.RA offers advantages over GA by reducing airway-related complications and fetal drug exposure, especially in resource-limited settings.
We believe these additions enhance the clarity and clinical relevance of our report. The revised manuscript has been updated accordingly.
Rapid stabilization of the patient was essential due to the need for an emergency cesarean section, hemodynamic stability, and improvement of APE before the anesthesia technique. Given the potential airway complications, risk of pulmonary aspiration, minimal fetal drug exposure, and the increased risk of cardio-cerebrovascular events associated with GA in preeclamptic patients, SA is the preferred technique. In this particular case, although GA might provide better hemodynamic control during the cesarean section, along with controlled ventilation and airway security, SA could be perceived as less favorable due to sympathetic blockade, more challenging hemodynamic management, and reduced vital lung capacity caused by decreased expiratory reserve volume from abdominal muscle paralysis. However, due to the patient’s normalized blood pressure and heart rate, resolution of lung crackles on auscultation, improved oxygen saturation, alleviation of respiratory distress, ability to tolerate the supine position, and acceptable echocardiographic findings, the decision was made to proceed with SA. Fortunately, the patient maintained stable vital signs and satisfactory clinical status throughout the surgery. For high-risk obstetric cases, a multidisciplinary approach involving obstetricians, anesthesiologists, and cardiologists is crucial to reduce maternal and neonatal morbidity and mortality. After adequate hemodynamic stabilization, SA may be considered a safe option even in severe preeclampsia with pulmonary edema, provided an experienced anesthesiologist performs it.