Introduction

The given study examines the susceptibility of pregnant obese women towards pre-eclampsia. Imrah is a 32-year-old female, who is currently in the third trimester of her pregnancy and belongs to the obese category. One evening after work, she started showing symptoms of indigestion, burning pain in the middle area between her ribs, headache and blurry vision. She is brought to the hospital by her husband and triaged as ATS Category 4 patient. However, a few moments later, she starts suffering from eclamptic seizure and undergoes an emergency cesarean section using general anesthesia.

This case study will critically analyze the sequence of events for the pre-eclamptic condition of Imrah, beginning from the onset of symptoms, eclamptic seizure, to the treatment strategies adopted and post operative care provided for the patient. In addition to this, a detailed emphasis will be laid on the peri-operative care provided to Imrah for effectively managing the seizures, performing an emergency cesarean section under general anesthesia and medical interventions used for providing high quality care to enhance the maternal and neonatal health. It will also highlight the importance of observing unusual symptoms in pregnant obese women and providing them with immediate medical assistance.

Part-A

Assessment in the Emergency Department

Imrah reported to the ED with symptoms of headache, blurry vision, indigestion, burning pain in the middle area of her ribs and fatigue. She is labeled as an ATS category 4 patient which suggests that her symptoms are severe but do not require critical (life-threatening) care (Channick et al., 2020). The symptoms shown by the patient directly point towards the onset of pre-eclampsia. Elevated blood pressure levels along with preoteinuria are the hallmark features of pre-eclampsia. Disturbances in the cerebral and visual organs are additional signs for the correct diagnosis of this medical condition. The functioning of the vital organs of the body such as kidney and liver are also affected by it (Karrar et al., 2024).

Since Imrah was in the 30th week of her gestation period, she should have been prescribed a detailed medical examination where her vitals such as blood pressure, respiratory rate and temperature should have been checked. A neurological examination should also have been performed to diagnose the consciousness and voluntary movements of the patient (Cabiddu et al., 2021). In addition to this, pathological tests namely CBC (complete blood count), kidney function test and liver function test should also have been prescribed to check the functioning of the liver and the kidneys, protein and creatinine concentrations in the urine (Hamadeh et al., 2021).

Pathophysiology of pre-eclampsia

In a healthy pregnant woman, the trophoblast cells attack the maternal spinal arteries. Following this invasion, the spinal arteries are collected to low resistance channels to regulate the supply of blood between the mother and the foetus. The progression of pre-eclampsia is divided into two phases, namely one prior to the 20th week of gestation and the other after the 20th week of gestaion period (Bisson et al., 2023).

In the early stage of pre-eclampsia, an insufficient amount of trophoblast cells attacks the spinal arteries. They do not undergo spinal remodeling and are not converted into low resistance channels. This lowers the supply of placental blood and creates a hypoxic and ischemic environment (Torres-Torres et al., 2024).

The later stage of pre-eclampsia stimulates the release of pro inflammatory cytokines such as TNF-?, IL-6 and angiogenic factors sFlt-1 and sEndo in response to the hypoxic environment. The systemic circulation of these factors damages the endothelium and increases the vascular activity (Torres-Torres et al., 2024).

Eclampsia is characterized by the occurrence of seizures. It denotes the transition of pre-eclampsia to eclampsia. The angiogenic factors and pro inflammatory cytokines in the systemic circulation invade the blood brain barrier which causes seizures. Cerebral vasospasm, endothelial dysfunction in the cerebral vasculature, and cerebral edema are some of the characteristics stages for eclampsia (Kornacki et al., 2023).

Monitoring and Treatment Escalation

A code blue is immediately called to stabilize Imrah after she experienced an eclamptic seizure. A cesarean section is performed under general anesthesia to manage the severity of her medical condition. This is an accurate decision taken by the medical practitioner to ensure the safety of both the patient and the mother.

The patient was intravenously administered with magnesium sulphate (5mg/hr) and hydralazine (1g/hr). Magnesium sulphate reduces the release of acetylcholine and blocks the neuromuscular junction, which relaxes the smooth muscles and prevents seizures (Magnesium Sulfate: Uses, Interactions, Mechanism of Action | DrugBank Online, n.d.). Hydralazine is used for the treatment of hypertension. These are the standard drug prescribed to a patient experiencing eclamptic seizures and hypertension (Hydralazine: Uses, Interactions, Mechanism of Action | DrugBank Online, n.d.).

Imrah was continuously intubated to maintain the oxygenation levels (SIMV- set rate of 10breaths per minute, VT 450mL, PEEP 5cmH,0, FiO, 0.4) and ventilated in the ICU. The readings of the Arterial blood gases (PaO2 of 125mmHg, PaCO2 of 35mmHg, pH of 7.34, and HCO3 of 18) indicated increased levels of pH and reduced biocarbonate levels. The patient was showing symptoms of mild metabolic acidosis as side effects of the magnesium sulphate and seizures (Zhang et al., 2022). Thus, the medical team in the ICU is trying to manage the hypertension and vitals of the patient.

The baby boy weighing 115 kg is immediately shifted to NICU (Neonatal Intensive Care Unit) to stabilize him. The baby is kept under observation to manage any complications in the future and perform detailed physical examination to relate the high weight with any abnormality.

The patient is extubated and removed from the ventilator as a result of improvement in the medical conditions of the patient. Her medication course is further modified. The intravenous intake of magnesium sulphate is stopped and enalapril (5mg) is prescribed for managing the hypertension. It is an orally administered drug which reduces the blood pressure levels by blocking the renin-angiotensin-aldosterone pathway (Enalapril: Uses, Interactions, Mechanism of Action | DrugBank Online, n.d.). This step-by-step approach followed by the medical practitioner helped in effectively managing the symptoms of pre-eclampsia and prevent any further complications.

Part-B

Peri-operative care includes all the three stages of surgery, namely pre-operative care followed by intra-operative care and post-operative care. Each phase has its own unique characteristic care and involves the role of different medical professionals suitable to the requirements of the patient and the surgery. It is very important to adhere to strict protocols during each phase of the peri-operative care to deliver high quality treatment to the patient.

Phase-1: Pre-operative

Imrah reports to the ED showing signs of indigestion, headache and blurry vision. She is categorized as ATC category 4 patient and made to wait. The medical professional should have immediately started the procedure for diagnosing the medical condition, considering the obesity and pregnancy (third trimester) of the patient. The medical professional should have monitored the vitals of the patients including blood pressure levels, respiratory rate and heart rate. Followed by this, a detailed pathological test such as urinalysis should have been recommended. This would have given an accurate diagnosis of pre-eclampsia to the doctor and measures could have been taken to avoid eclamptic seizures.

There is a high risk involved in administering Imrah with general anesthesia due to obesity and pre-eclampsia during the third trimester of her pregnancy. It has been found that using general anesthesia in pregnant obese women increases the risk of maternal mortality. The administration of general anesthesia makes it difficult to perform intubation, aspiration and hypoxia (Mossie et al., 2022). The Caesarean section performed in emergency did not involve an expert guidance from the anesthetic. It is generally recommended to use neuraxial anesthesia, which is administered near the spinal cord region and is safe for both, mother and the baby (Olawin & Das, 2022).

Koda is very alert in observing the unusual symptoms of her wife (Imrah). He understands the severity of the medical condition and immediately brings Imrah to the hospital. His knowledge and observations to the unusual symptoms in pregnant obese women, helped in accurately diagnosing pre-eclampsia and prevent any complications to the baby.

Phase-2: Intra-operative

Considering Imrahs medical scenario, it is very important to assess the path for airway before performing intubation. It is observed that pregnancy along with obesity leads to failed intubation. Thus, it is very important to select an appropriate anesthetic technique for maintaining the cardiovascular stability and respiratory rate. In addition to this, it is also essential to continuously monitor the vitals of the patient such as heart rate, blood pressure, oxygen saturation to avoid any serious complications such as bleeding and hypotension (Tan & Habib, 2021).

During the surgery, the patient is accurately positioned to prevent any injury or discomfort. Preoxygenation is generally performed in Reverse Trendelenburg position, to increase the time duration for reaching sleep apnoea. After evaluating the airway paths, the patient is intubated in a ramped position. For this position, it is important to horizontally align the auditory meatus and sternal notch. All these parameters are carefully considered while performing an emergency cesarean section on the patient with general anesthesia (Simon et al., 2020).

The baby boy delivered by the patient weighs 1150g. The well-being of the baby is examined in detail, where the Apgar scores are reported to be 4 at one minute and 7 at 5 minutes. The Apgar scores of the baby fall in the normal range, however the weight of the baby is quite low. For understanding the reason behind low weight and providing protection against external infections, the baby is immediately transferred to the neonatal intensive care unit.

Phase-3: Postoperative Care

Imrah is provided critical care in the intensive care unit after the surgery. The patient is required to be continuously monitored to prevent any further infection or internal bleeding. She is neurologically examined to determine the impact of eclamptic seizures. The vitals are kept in check to keep a record of the blood pressure levels after the surgery. The Arterial Blood Gas levels of the patient reveals that the patient is suffering from mild metabolic acidosis due to the eclamptic seizures (Lactic Dehydrogenase Enzyme and Acid-Base Status in Severe Preeclampsia: A Case-Control Study Investigating the Impact of Obesity - Archive Digital, n.d.).

Imrah is continuously intubated and ventilated after the surgery. The variables of the ventilator machine are set at SIMV- set rate of 10breaths per minute, VT 450mL, PEEP 5cmH,0, FiO, 0.4. These variables were defined to avoid any lung associated injury to the patient. Thus, a support is provided to the respiratory system of Imrah, as she has faced seizures and undergone a massive surgery.

The medications of the patient are regularly modified on observing signs of improvement. Initially, Imrah is intravenously administered magnesium sulphate and hydralazine. To prevent any further eclamptic seizures, the dosage of the magnesium sulphate is set at 1g/hr. This was ceased with improving neurological state of the patient. For lowering the blood pressure levels, hydralazine is prescribed. Since, the blood pressure levels are monitored, the patient is transitioned to an oral antihypertensive drug namely Enalapril. The dosage of this drug is set at 5mg/hr.

Conclusion

The critical analysis of the case study provides an insight on the medical strategies utilized to provide immediate treatment to pregnant obese women showing signs of pre-eclampsia. Initially, the timely observation of unusual symptoms by Koda helps the patient to seek clinical guidance immediately. The decision to perform immediate cesarean section after Imrah experienced eclamptic seizure is also very accurate, as it ensured the well-being of both the mother and the baby. The newborn is thoroughly examined and kept under observation in the neonatal intensive care unit to protect the baby from any external infections. Also, high-quality post operative care is provided to her. The vitals are monitored, and standard medications are prescribed by the doctor to reduce her blood pressure levels and avoid the occurrence of eclamptic seizures again.

Although the patient is categorized under ATC category 4, no thorough examination is conducted to check her parameters. The observations obtained from the pathological tests would have helped the doctor to diagnose the pre-eclamptic condition of Imrah and prevent the onset of seizures in the first place. Followed by this, general anesthesia used for performing emergency cesarean section is also advised to be avoided as it is dangerous for pregnant obese women. Thus, this case study denotes the effective critical care provided for managing the pre-eclamptic condition of Imrah but also highlights the importance of detailed treatment procedures to avoid the worsening of medical situations like these.

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