Acta Anaesthesiol Taiwan 2008;46(1):46−48

C ASE R EPORT

Eclampsia Following Cesarean Section with

HELLP Syndrome and Multiple Organ Failure
Shun-Ming Chan1, Chih-Cherng Lu1, Shung-Tai Ho1, Wen-Jinn Liaw1,
Chen-Hwan Cherng1, Wei-Hwa Chen2, Tso-Chou Lin1*
1
Department of Anesthesiology, Tri-Service General Hospital, School of Medicine, National Defense
Medical Center, Taipei, Taiwan, R.O.C.
2
Department of Gynecology and Obstetrics, Tri-Service General Hospital, School of Medicine,
National Defense Medical Center, Taipei, Taiwan, R.O.C.

Received: Oct 12, 2007
Revised: Dec 11, 2007
Accepted: Dec 14, 2007
KEY WORDS:
eclampsia;
HELLP syndrome;
multiple organ failure;
postpartum period
We present a rare case of postpartum eclampsia with overt acute heart and renal
failure, in the absence of any precursive signs of preeclampsia. A 41-year-old par-
turient underwent elective cesarean section for the delivery of twins under spinal
anesthesia. Prior to the procedure, preoperative laboratory examination revealed
only traceable proteinuria but she had hypertension perioperatively. Approximately
8 hours after the cesarean section, she developed seizures, followed by evident
acute heart and renal failure. The diagnosis of postpartum eclampsia with HELLP
(hemolysis, elevated liver enzymes and low platelets) syndrome was established
and she was admitted to the surgical intensive care unit for close care. Fortunately,
the patient recovered fully and was discharged 26 days later. From this illustrative
example, unexplainable and sustained hypertension following cesarean section should
serve as a signal to warn the health care staff concerned about the possibility of
impending life-threatening postpartum eclampsia.

1. Introduction in a parturient whose blood pressure has remained

Hypertensive disease occurs in approximately 12−22%
of pregnancies, and it is directly responsible for
17.6% of maternal deaths in the United States.1
Eclampsia, characterized by preeclamptic signs with
a seizure, is a serious and unpredictable accompa-
niment to pregnancy-induced hypertensive disor-
ders. Postpartum eclampsia usually happens during
the first 48 hours after delivery, but in some cases,
it may occur up to 16 days after delivery.2 HELLP
syndrome is a rare obstetric problem characterized
by hemolysis, elevated liver enzymes, and low plate-
let counts.3 Severe preeclampsia, associated with
HELLP syndrome, can occur after a normal delivery
normal throughout the antenatal period.4 This case
report illustrates a consequence of eclampsia asso-
ciated with epigastric pain and unexplainable hy-
pertension in a parturient after a normal pregnancy
and delivery.
2. Case Report
A 41-year-old woman, height 161 cm and body weight
64 kg, was admitted for labor at 38 weeks of gesta-
tion, and cesarean section was indicated because
of twin pregnancy with malpresentation. Her preg-
nancy was uneventful and her blood pressure was

*Corresponding author. Department of Anesthesiology, Tri-Service General Hospital, 325, Section 2, Cheng-Gong Road,
Nei-Hu District, Taipei 114, Taiwan, R.O.C.
E-mail: linjozo@yahoo.com.tw

©2008 Taiwan Society of Anesthesiologists

Postpartum eclampsia and multiple organ failure
essentially normal. Routine urine analyses had shown
a trace of protein at 32 and 38 weeks of gestation,
but was otherwise normal. Preoperative laboratory
examinations were unremarkable, i.e., hemoglobin,
11.9 g/dL; platelet count, 142 × 109/L; blood urea
nitrogen (BUN)/creatinine, 14/0.6 g/dL; aspartate
aminotransferase (AST)/alanine aminotransferase
(ALT), 25/33 U/L and a normal coagulation profile.
After intravenous hydration with Ringer’s solution
1000 mL, spinal anesthesia was induced with 10 mg
of 0.5% hyperbaric bupivacaine via the L3−4 inter-
space, which initially achieved sensory blockade
up to the T8 level without cardiovascular com-
promise. Both twins were delivered uneventfully
and blood pressure and heart rate remained around
140/90 mmHg and 70 beats/min. However, epigas-
tric pain developed while the placenta was removed.
Ketamine 50 mg was administered intravenously
and the patient’s blood pressure increased to 180/
110 mmHg. Intermittent intravenous infusion of
nitroglycerin was prescribed to bring her blood
pressure down to 150/90 mmHg. The operation was
completed uneventfully and she was returned to
the ward with full consciousness, but she needed
sublingual nifedipine to control blood pressure
under 150/100 mmHg. Eight hours later, she suf-
fered from shortness of breath and a generalized
seizure, and loss of consciousness and hypotension
(70/40 mmHg) immediately followed. Emergency
resuscitation including endotracheal intubation,
intravenous magnesium sulfate, epinephrine, and
continuous infusion of dopamine was performed,
which kept her vital signs stable (blood pressure,
110/70 mmHg; heart rate, 106/min). She was trans-
ferred to our surgical intensive care unit for fur-
ther investigation and management. The diagnosis
of HELLP syndrome was established, as evidenced
by the presence of anemia (hemoglobin concentra-
tion, 8.9 g/dL) and thrombocytopenia (platelet
counts, 44 × 109/L), along with markedly elevated
liver enzymes (AST, 1531 U/L; ALT, 1154 U/L). Dexa-
methasone 5 mg intravenously twice daily was then
given for the next 3 days. Meanwhile, acute renal
failure (< 100 mL urine in the first 4 hours; BUN,
32 mg/dL; creatinine, 2.2 mg/dL) was treated with
an intravenous infusion of furosemide and ade-
quate hydration. Fortunately, renal function grad-
ually recovered to the normal range 9 days later.
In addition, acute heart failure was confirmed by
transthoracic echocardiography, which revealed a
dilated left ventricle with generalized hypokinesia
and severe mitral regurgitation. Continuous infusions
of dobutamine and nitroprusside were administrat-
ed to keep the hemodynamics stable. A secondary
echocardiography performed 7 days later demon-
strated improved left ventricular systolic function
with mild mitral regurgitation. Magnesium sulfate
47
was also given to prevent recurrent eclamptic sei-
zures. During the episode of renal failure, hypermag-
nesemia as high as 7.5 mg/dL (normal range being
1.58−2.55 mg/dL) was found and persisted in the ini-
tial days, associated with generalized muscle weak-
ness. She was given intravenous calcium gluconate
1 g intermittently for five doses to antagonize ex-
cessive magnesium sulfate. However, the patient was
not extubated until the magnesium concentration
fell to 1.6 mg/dL on the 9th day. She was discharged
from the ward on the 26th day without any sequelae.
3. Discussion
Preeclampsia-eclampsia occurs in 6−8% of all preg-
nancies.5 Eclampsia, defined as the occurrence of
seizures in pregnant women without other neuro-
logical disorders, occurs mainly before, during, or
within 48 hours of delivery.6 It often occurs when
signs and symptoms of preeclampsia are ignored or
are not detected because of deficient prenatal care.
However, a majority of cases develop seizure at-
tacks in well-managed hospitals, even in industri-
alized countries.7 When convulsions occur in the
postpartum period as long as 16 days after birth,2
making an accurate diagnosis is more difficult. Late
onset postpartum eclampsia can even occur in nor-
motensive women with uncomplicated pregnancies,
not to mention those with preeclampsia.8 Approxi-
mately 40% of women who experienced eclampsia
late in the postpartum period failed to manifest
classic clinical signs and symptoms of preeclamp-
sia.9 They always had prodromal symptoms such as
malaise, headache, nausea, vomiting, and blurred
vision prior to the onset of eclampsia.
Eclampsia can also be accompanied by life-
threatening complications, such as pulmonary edema,
renal and hepatic failure, disseminated intravas-
cular coagulopathy, and HELLP syndrome.6 HELLP
syndrome, with manifestations of hemolysis, ele-
vated liver enzyme and low platelet count, was
first described in 1954.10 Its severity ranges from a
mild and self-limited course to a fulminant process
leading to multiple organ failure. In rare cases,
HELLP syndrome has occurred in normotensive preg-
nancy, only with epigastric pain and tenderness on
palpation at the right hypochondrium as initial symp-
toms.4 In most cases, the postpartum HELLP syn-
drome would resolve spontaneously within 48 hours.
A profound thrombocytopenia in the antenatal pe-
riod may indicate a higher risk of HELLP syndrome.
A short course of postpartum therapy with dexa-
methasone has proved helpful for thrombocytopenia
in a parturient with HELLP syndrome.11
Ketamine, a dissociative anesthetic with elimina-
tion half-life of 2.17 hours,12 has unique cardiovascular
48
effects. It stimulates the cardiovascular system, usu-
ally resulting in increases in blood pressure, heart
rate, and cardiac output,13 and it should be used
with exceptional caution in patients with known
preeclampsia. However, there is no available report
on ketamine-induced preeclampsia or eclampsia.
In this case, we had only administered ketamine
50 mg (< 1 mg/kg) as an anesthetic adjuvant, the ef-
fect of which would not last beyond 8 hours in the
postpartum. Therefore, unexplainable and persist-
ent hypertension following a single-dose adminis-
tration of ketamine in a surgical parturient should
serve as an indication for careful monitoring for the
signs of preeclampsia and postpartum eclampsia.
Magnesium sulfate is an effective agent for
control and prevention of recurrence of eclamptic
seizures.14 The normal plasma concentration of mag-
nesium sulfate ranges between 1.58 to 2.55 mg/dL.
A higher therapeutic plasma concentration of mag-
nesium sulfate between 4 and 7 mg/dL, has been
recommended to prevent recurrence. Most plasma
magnesium is eliminated by the kidneys, and there-
fore accumulation may occur in patients with acute
renal failure. Manifestations of hypermagnesemia
include muscle weakness, decreased deep tendon
reflex, and depressed cardiovascular performance,14
all of which can further reduce renal perfusion and
hemodynamic stability. The persistent muscle weak-
ness induced by hypermagnesemia appeared in the
first several days while the patient was in acute
renal failure. Calcium gluconate was used as an
antagonist for hypermagnesemia. However, our pa-
tient was not extubated until 9 days later when
the plasma concentration of magnesium had fallen
within normal ranges.
With changing procedures over the past two
decades, regional anesthesia has become the pre-
ferred technique for women with severe preeclamp-
sia or eclampsia for both labor and surgical delivery.15
The occurrence of regional anesthesia-related hy-
potension can usually be avoided by meticulous
attention to maintenance of anesthesia, the use of
ephedrine and careful volume expansion. Epidural
anesthesia/analgesia for labor in a preeclamptic
patient offers the advantage of a gradual onset of
sympathetic blockade. It maintains cardiovascular
stability and avoids neonatal depression. Recently,
many studies have demonstrated spinal anesthesia
can be equally safely used in patients with severe
preeclampsia undergoing cesarean delivery.15−17 The
fluctuation of perioperative maternal blood pres-
sure in spinal anesthesia did not differ from epidural
anesthesia, and thus both appear to be equally safe
regional anesthetic techniques.15
In conclusion, we present a rare case of post-
partum eclampsia with HELLP syndrome and multi-
ple organ failure, which emerged in the wake of
S.M. Chan et al
epigastric pain and unexplainable hypertension after
cesarean section delivery, with the aim of sharing
our increased understanding of the warning signs of
this condition. Awareness of and early prevention
against preeclampsia may help reduce the occur-
rence of postpartum eclampsia.
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