Anesthetic Management in for Emergency Caesarean Section

in Pregnant Women with Meningioma

Nelly Margaret, Dewi Yulianti Bisri, Tatang Bisri

Departement of Anesthesiology and Intensive Care

Padjadjaran University Faculty of Medicine
Dr. Hasan Sadikin General Hospital
Bandung

Introduction
Brain tumours in pregnant patients impose a unique risk to both the foetus and mother.1 Problem in patient with brain tumor is effects of mass
that increases intracranial pressure (ICP). Hyperventilation will decrease uterine pressure blood flow and decrease APGAR score. Emergency
caesarean section requires general anesthesia that increases the risk of vomiting and aspiration during induction.

Case Report
A woman, 41 years old, height 150 cm and weigh 60 kgs, G5P3A1 at 36 – 37
weeks gestation with intracranial tumor at cerebellum due to meningioma and fetal
distress underwent emergency caesarean section in general anesthesia. There was
neurological disorder (paresthesia, hemiplegia) and signs of increasing intracranial
pressure (frequent severe headache with blurred vision). Preinduction, she was
conscious, with blood pressure 134/87 mmHg, heart rate 106 bpm, respiratory rate
22 times per minute, and saturation 98% with binasal canule 3 liter per minute,
with decreasing fetal heart rate, 110 beats per minute.
After premedication with ranitidine and metoclopramid, induction was
performed with lidocaine 90 mg, fentanyl 120 mcg, propofol 120 mg, and
rocuronium 75 mg. Sevoflurane was opened at 2 vol% with O2 and air. Intubation
with ETT No. 6,5. Maintenance with sevoflurane 1 – 2 vol% with O2 and air.
Hemodynamic was stable during surgery. Female baby was delivered with
APGAR 5/9. Urine output 80 cc in 1,5 hour. At the end of surgery, patient was
extubated in deep anesthesia.

Discussion
Key points for anesthesia in pregnant patient with brain tumor is focused on the mother with consideration to the foetus. Beside the ABCDE
neuroanesthesia, physiological changes in pregnancy and principles of obstetric anesthesia has to be considered.
The decision to proceed a standard rapid-sequence induction without ventilation must weigh the risk of aspiration against the patient’s level
of increased intracranial pressure and ability to tolerate a period of hypercarbia.4
In this patient, premedication with metoclopramide and ranitidine was given before induction. After patient was apneic, ventilation was given
with lower tidal volume and higher frequency to provide enough minute volume without insufflating the gaster, which can reduce aspiration risk.
Hemodynamic surge at intubation, incision, and extubation should be avoided with the use of lidocaine and fentanyl.5 Propofol was also used for
induction in this patient due to its effect to decrease CBF, ICP, and CMRO2. All volatile increases CBF but minimal for sevoflurane (sevoflurane <
isoflurane < enflurane < halothane). 5 Intraoperative, SBP was maintained > 90 mmHg to maintain Cerebral Perfussion Pressure and Uterine
Blood Flow. The use of fentanyl in this patient does not worsen the APGAR score of the baby (APGAR score 5/7/9).After surgery, extubation was
performed in deep anesthesia with prior intravenous lidocaine 60 mg and fentanyl 30 mcg at the end of surgery to prevent hemodynamic surge
during extubation and coughing that can increase ICP.

Conclusion

Surgical intervention in a pregnant patient with brain tumor is rare but

poses many challenges to the attending anaesthesiologist. Reference

Anesthesiologist's should be aware of these concerns to provide optimal care 1. Bisri, Dewi Yulianti. Tatang Bisri. 2015. Anestesi Untuk Tumor.Otak Supratentorial Infratentorial.FK UNPAD.
2. Cottrell, James. Young, William. Neuroanesthesia. 2010. Mosby Elseviere. Philadelphia; 23 : 420 - 421
3. Subramanian, Rajkumar.et al. 2014. Neurosurgery and Pregnancy. Journal of Neuroanesthesiology & Critical Care. India.
to both the mother and foetus for good outcome. Diakses dari http://www.jnaccjournal.org