Rapid Sequence Intubation, Tiered Anticonvulsant Escalation and Continuous Furosemide Infusion in Severe Eclampsia with Acute Pulmonary Edema: A Case Report

Abstract

Background. Eclampsia with acute pulmonary edema is a life-threatening obstetric emergency in which seizure control, airway management and fluid strategy compete.

Objective. To describe the airway, anticonvulsant, ventilatory and fluid management of one parturient with eclampsia, acute pulmonary edema and premature rupture of membranes, and her outcome.

Methods. A 28-year-old nulliparous woman at 38 weeks and 4 days presented after two generalized tonic-clonic seizures, with blood pressure 168/95 mmHg, Glasgow Coma Scale (GCS) 12, bilateral basal crackles and SpO₂ 92% on room air. Emergency cesarean delivery was done under rapid sequence general anesthesia after sevoflurane pre-oxygenation. In the intensive care unit (ICU) she received magnesium sulfate, a continuous furosemide infusion (5.0 mg/h) and low tidal volume ventilation.

Results. Intubation was uneventful, and a male neonate was delivered (3,420 g; Apgar 7, 8 and 9). Within 45 minutes of ICU arrival, three seizures occurred despite magnesium sulfate 1.0 g/h. A midazolam infusion (1.5 mg/h) and phenytoin (100 mg) were added, and no further seizures followed. The cumulative net fluid balance reached −2,800 mL over 72 hours with stable creatinine. She was extubated at hour 16 with GCS 15. Mother and neonate went home on postoperative day 4; her blood pressure was normal at six weeks.

Conclusion. In this patient, rapid sequence induction, escalation of anticonvulsants, low tidal volume ventilation and continuous loop diuresis were followed by survival of mother and neonate. A single case cannot show that any one component caused the recovery.