Challenges of Providing Optimal and Safe Intrapartum Analgesia in Patients With HELLP Syndrome: A Case Report and Literature Review

Abstract

ABSTRACT HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) Syndrome is a rare but serious complication of pregnancy that can lead to disseminated intravascular coagulation, pulmonary edema, respiratory failure, hepatic and renal injury, and death if not recognized and treated promptly. A 36-year-old nulligravid (G0) active duty Marine at 36 weeks and 1 day gestation with dichorionic diamniotic twins presented to triage for routine cervical examination found to have elevated blood pressures and symptomatic thrombocytopenia, with a suspected diagnosis of HELLP. A multidisciplinary decision was made by anesthesiology, obstetrics and gynecology, and pediatrics to deliver the twins to avoid any further complications. The twins were in cephalic presentation and the patient desired to attempt a vaginal delivery. Due to the patient’s thrombocytopenia, neuraxial anesthesia (spinal and/or epidural) left the patient at a high risk of developing catastrophic complications such as an epidural hematoma, and the subsequent motor block/weakness would likely lessen the patient’s ability to participate in active labor for a vaginal delivery. A Cesarean section under general anesthesia was also to be avoided as the patient’s elevated risk of catastrophic hemorrhage would be worsened by volatile anesthetic agents which cause significant uterine vascular relaxation and reduced uterine muscular tone. Ultimately, the decision was made to provide analgesia through a remifentanil PCA (patient-controlled analgesia) for labor and a ketamine bolus for delivery. The mother delivered both twins vaginally in the operating room without perioperative complication. This case demonstrates the safety of alternate forms of anesthesia for delivery when neuraxial anesthesia is contraindicated.