Management of a Parturient with Preeclampsia and

HELLP Syndrome Complicated by Gestational

Diabetes Insipidus

Pembimbing :
Dr. Karyadi P, SpAn

Disusun oleh :
Hilda C Y Muda
1161050172
 Introduction

Severe
Severe preeclampsia
preeclampsia
BP
BP >160/110
>160/110 mmHg,
mmHg, proteinuria
proteinuria >5
>5 grams/day,
grams/day,
oliguria
oliguria (<500
(<500 mg/day),
mg/day), elevated
elevated serum
serum creatinine,
creatinine,
intrauterine
intrauterine growth
growth restriction,
restriction, pulmonary
pulmonary edema,
edema,
neurologic
neurologic manifestations
manifestations ,, hepatic
hepatic tenderness
tenderness or
or HELLP
HELLP
syndrome.
syndrome.

GDI
GDI is
is known
known to
to be
be associated
associated with
with HELLP
HELLP
and
and HELLP
HELLP is
is known
known to
to be
be associated
associated with
with
GDI
GDI
 Introduction

Preeclampsia
Preeclampsia accounts
accounts for
for
approximatel
approximatel 15.9%
15.9% of
of all
all maternal
maternal
deaths
deaths in
in the
the US
US and
and GDI
GDI as
as rare
rare
complication
complication of
of pregnancy
pregnancy inin about
about
4
4 out
out of
of 100,000
100,000 pregnancies.
pregnancies.

The
The anesthetic
anesthetic goals
goals :: minimize
minimize vasospasm,
vasospasm, achieve
achieve
blood
blood pressure
pressure control,
control, improve
improve circulation,
circulation, optimize
optimize
intravascular
intravascular volume
volume and
and correct
correct electrolyte
electrolyte and
and acid
acid
base
base disturbances
disturbances without
without over
over correcting
correcting the
the
hypernatremia.
hypernatremia.
 Case Report

History taking

41-year-old
41-year-old African
African American
American female,
female, G3P3,
G3P3, with
with no
no significant
significant past
past medical
medical
problems
problems and
and history
history of
of two
two previous
previous Cesarean
Cesarean sections,
sections, presented
presented at
at 38
38 weeks
weeks
of
of gestational
gestational age
age to
to the
the patient
patient presented
presented to
to obstetrical
obstetrical clinic.
clinic. Her
Her presenting
presenting
complaints
complaints were
were polyuria,
polyuria, polydipsia,
polydipsia, weakness,
weakness, and
and headache
headache ofof two
two days
days
duration.
duration.

Blood
Blood pressures,
pressures, systolic
systolic blood
blood pressure
pressure ranging
ranging from
from 160
160 -- 170
170 mm
mm ofof Hg,
Hg,
diastolic
diastolic blood
blood pressures
pressures 90
90 -- 100
100 mm
mm of of Hg
Hg and
and heart
heart rate
rate in
in the
the range
range of
of 100
100 --
120
120 beats
beats per
per minute.
minute. She
She denied
denied anyany blurring
blurring ofof vision,
vision, epigastric
epigastric pain,
pain,
neurological
neurological abnormalities
abnormalities or
or breathing
breathing difficulties.
difficulties. Examination
Examination of of the
the systems
systems
did
did not
not reveal
reveal any
any significant
significant findings
findings..
Hematocrit :42 % Renal function
Platelets 235,000/ Ul Uric acid of 8.9 mg/dl
BUN 15 mg/dl
Liver function Creatinine of 1.2 mg/dl.
Serum AST 270 IU/L,
ALT 271 IU/L,
Electrolytes
LDH 379 IU/L,
Sodium 148 mmols/L
Alkaline phosphatase 207
IU/L, Chloride 121 mmols/L,
Albumin 2.9 IU/L potassium 4.6 mmols/L.
Total bilirubin 0.7 mg/dl.
Serum ADH : <1.0 pg/ml
* Patient received a bolus of 4 grams of magnesium sulfate for
eclampsia prophylaxis. Two units of PRBCs were typed and
cross-matched

* Combined Spinal Epidural(CSE) at l3-L4 interspace with

preservative free morphine 0.3 mg, fentanyl 15 ug, and 1.5
ml of hyperbaric bupivacaine 0.75% with dextrose 8.5 mg/ml.

* Intraoperative fluid management consisted of the

administration of 2200 ml of lactated Ringers over a period of
100 minutes.
Postoperative :
Serum sodium high calculated, Serum Osmolality 331 ,
, urine output > 2000 ml over a period of 5 hours
medical intensive care unit for hydration, blood
pressure monitoring and correction of hypernatremia.

0.9% normal saline infusion at 300 ml/hr was

initiated, which was titrated to achieve a goal of
sodium correction rate of less than 10 mEq in twenty
four hours or 0.5 mEq/hr.
 Discussion

Diabetes insipidus is a rare phenomenon and

commonly presents at the end of the second or
during the third trimester of a first pregnancy.

Diabetes insipidus manifestation cause deficit

in the secretion of ADH (Antidiuretic Hormone)
from the hypothalamus and is renal tubular
insensitivity to ADH (antidiuretic hormone), deficit
in ADH production, secondary to excessive fluid
intake because of psychogenic polydipsia..
Diabetes insipidus manifestation cause deficit in the
secretion of ADH (Antidiuretic Hormone) from the
hypothalamus and is renal tubular insensitivity to ADH
(antidiuretic hormone), deficit in ADH production, secondary to
excessive fluid intake because of psychogenic polydipsia.

Symptoms of DI polyuria, polydipsia, fatigue, nausea,

weight loss, and decreased skin turgor. Disturbances in
hydration become evident in obtunded or comatose patients
because of their inability to compensate for increased
urinary losses.
GDI can be suspected when serum osmolality is equivalent
to that of a non-pregnant woman (285 mosmol/L) with
urinary osmolality under 300 mosmols/L

Blood glucose levels are usually normal in GDI.

Plasma levels of ADH should be assayed in the
presence of a vasopressinase inhibitor since
parturients have high concentrations of cysteine
aminopeptidase which degrades vasopressin in vitro..
 The focus of perioperative management is on:

Blood pressure control with appropriate antihypertensive

medications;
Seizure prophylaxis with Magnesium therapy;
Strict intake-output monitoring;
Cautious administration of fluids, avoiding a rapid fall in
serum sodium concentration of no more than 0.5 meq/hour to
prevent cerebral edema;
Treatment with desmopressin;
 Expeditious delivery of the fetus and placenta (delivery
of the placenta alleviates the GDIas well as the HELLP
syndrome and preecamplcia.);
Utilizing spinal/epidural blocks- preferable since
monitoring of the mental status and avoidance of the
airway is facilitated;
Invasive hemodynamic monitoring-;
Continued postoperative care in a monitored setting is
highly desirable.
Frequent monitoring of serum electrolytes;
Blood pressure control and magnesium sulfate for eclampsia
prophylaxis, but the definitive treatment for her preeclampsia,
HELLP syndrome, and gestational diabetes insipidus was the
delivery of fetus and placenta .

The use of an arterial line not only allows for expeditious

monitoring and treatment of elevated blood pressures but also
allows for close monitoring of electrolytes and creatinine
postoperatively

Central venous pressure monitoring in addition to arterial line

monitoring has been described in GDI to assist with careful volume
resuscitation in the setting of suspected dehydration.
Hypernatremia leads to increased local anesthetic potency
due to the increased intra-extra neural sodium gradient and
careful titration and administration of the local anesthetics
is essential.

Administration of intranasal desmopressin is the

treatment of choice in GDI

Caution desmopressin overdose hyponatremia

Patients with gestational diabetes insipidus may require
intranasal desmopressin spray 5 mcg twice a day after an
initial dose of 10 mcg. Breastfeeding can stimulate secretion
of ADH and the dose of desmopressin can be decreased.

Alternative treatment is
hydrochlorothiazide.
 * Conclusion
During pregnancy, the diagnosis of DI is not easy to consider since
polyuria in pregnancy is generally considered normal. In general,
GDI per se does not seem to result in serious complications. versus
the potential benefits of expectant management to further fetal
maturation.