Emergency caesarean delivery in a patient with cerebral malaria-leptospira co infection: Anaesthetic and critical care considerations
A 24-year-old primigravida, at 37 weeks of gestation was referred to our institute for further management on supplemental oxygen (Venturi mask) after Rapid test diagnosis of Plasmodium falciparum (Pf) malaria (ParaSight™-F, Becton Dickinson, Sparks, MD) associated with acute icteric leptospirosis (microscopic agglutination test (MAT) titers for Leptospira ictero-haemorrhagiae of 1:400). Her history revealed high grade fever, decreased urine output with yellowish discolouration and altered sensorium. She was disoriented, febrile and icteric and had sub-conjunctival haemorrhages and fine basal crepitations on auscultation. She was receiving intravenous (i.v.) artesunate and ceftriaxone and doxycycline capsules. Her pre-operative investigations in referral card revealed anaemia, jaundice with deranged liver function, coagulopathy, thrombocytopenia, increased total leucocyte count, elevated blood urea nitrogen and serum creatinine. Abdominal ultrasonography showed a singleton pregnancy, adequate liquor, umbilical artery systolic-diastolic ratio of 2:1 and mild hepato-splenomegaly. Within 1 h of arrival she was posted for emergency caesarean delivery because of non-reassuring fetal heart rate [].\nAfter administering aspiration prophylaxis and taking high-risk consent she was shifted to operation theatre. Basic monitors were attached and rapid sequence intubation with cricoid pressure was carried out using thiopental and succinylcholine. Right internal jugular vein and left radial artery were cannulated under ultrasonographic guidance simultaneously by two anaesthetists. Her baseline serum glucose level was normal. Anaesthesia was maintained with isoflurane in N2O-O2 mixture and atracurium until delivery of a 2.25 kg baby. After cord separation, fentanyl was administered. Oxytocin (25 IU) infusion was started in titrated doses. Neonatal data recorded were an Apgar score of 6 and 8 at 1 and 5 min respectively, with cord blood pH of 7.28, base deficit of 5.4 and blood sugar level of 50 mg/dl. Hypotension started after placental separation. Blood loss was managed with packed red blood cells, fresh frozen plasma and platelets transfusion followed by noradrenaline infusion (titrated doses). At the end of the surgery, blood gases showed mild acidosis, but normal electrolytes and serum glucose. She was shifted to intensive care unit (ICU) in intubated state and on noradrenaline infusion. Post-operative analgesia was maintained by ultrasound guided bilateral transverse abdominis plane block. In ICU, on the second postoperative day, she developed pulmonary haemorrhage []. Considering coagulopathy, blood products were transfused, but it did not benefit. Bed side fibre-optic bronchoscopy was carried out, which revealed erythematous mucosa, blood clots, active oozing and diffuse bleeding from distal airway. Broncho alveolar lavage was performed and Factor VIIa (AryoSeven, AryoGen Biopharma Co, Tehran, Iran) was administered (50 μg/Kg of rFVIIa in 50 ml distrilled water through the fibre-optic bronchoscope (25 ml in each main bronchus after lavage) because of its thrombogenic effect. Following this immediate bleeding cessation and significant reduction of inspired oxygen fraction (FiO2) was observed in the next 12 h. Her chest radiograph, which showed bilateral non-homogeneous opacities (lower and middle zones), the previous day became almost clear the next day. In view of acute kidney injury, severe hyperbilirubinemia and blood picture indicating haemolytic uremic syndrome (high serum lactate dehydrogenase, schistocytes in peripheral blood), nephrology opinion was obtained and based on their suggestion, plasmapheresis followed by dialysis was done (seven cycles each). Because of the altered mental status, computed tomography of the brain was carried out, which showed diffuse cerebral oedema. for which cerebroprotective measures (head elevation, not rotating neck, maintain serum sodium 145-155 Meq/L, keeping blood partial pressure of carbondioxide 32-40 mmHg) were undertaken. Other investigations such as blood cultures, urine cultures, Weil-Felix test, typhi dot, dengue, and hepatitis viruses serology yielded negative results. Supportive therapies like stress ulcer prevention, deep vein thrombosis prophylaxis (pneumatic compression) and glycemic control were provided. By the fourth post-operative day, the intensity of fever started reducing, consciousness improved, inotropic support tapered, urine output improved and liver function test with coagulation parameters showed improving trends. Her Pao2/Fio2 ratio also gradually improved. By the sixth post-operative day, she could be extubated. Subsequently, she was shifted to wards and safely discharged from the hospital.