Not All Swelling Is Edema in Eclampsia: A Rare and Life-threatening Potential Complication of Eclamptic Seizures

Abstract

A 24-yr-old, 65-kg, 152-cm primigravida woman with severe pre-eclampsia and a history of asthma was admitted at 38 weeks’ gestationfor magnesium administration and oxytocin induction of labor. Herlaboratory studies and physical examination were within normal limitsexcept for proteinuria, hypertension, and moderate generalized edemawithout obvious facial edema at admission. Because of her preeclamp-sia, an epidural catheter was easily inserted early before onset of activelabor or pain. Three hours later, the patient had a witnessed tonic–clonic eclamptic seizure, which subsided shortly after administrationof 4 mg intravenous lorazepam and assisted mask ventilation. Becauseof recurring fetal heart rate deceleration, an urgent cesarean deliverywas planned. However, the patient was combatively uncooperativedespite a bilateral T4 anesthetic level achieved epidurally while heroxygen saturation remained 100% and blood pressure was 140/85mmHg. The patient was noted to have a Mallampati class I airway withmoderate generalized edema and mild facial edema. Rapid sequencegeneral anesthesia induction was performed with successful atrau-matic intubation on the first attempt, followed by verification of bilat-eral symmetrical breath sounds. Maintenance of anesthetic consisted ofvolume-controlled mechanical ventilation, 50% oxygen, 50% nitrousoxide, 1–2% sevoflurane, midazolam, and opioid without the need foradditional neuromuscular blocker other than succinylcholine at induc-tion. Intraoperative blood pressure and heart rate were maintainedwithin 20% of preoperative values while oxygen saturation was main-tained at 99–100%, end-tidal carbon dioxide between 30–35 mmHg,and airway pressures less than 25 cm H