Background: The management of obstetric patients with concurrent hypercoagulable disorders, hypertensive emergencies, and cerebrovascular complications presents significant anesthetic challenges. Factor V Leiden deficiency, the most common inherited thrombophilia, significantly increases the risk of venous thromboembolism (VTE) in pregnancy, already a hypercoagulable state 1. Moreover, preeclampsia with severe features, associated with end-organ damage, is a leading cause of maternal morbidity and mortality, contributing to complications such as intracranial hemorrhage (ICH) 2. These in addition to a premature gestation complicated by posterior placenta previa, requires a multidisciplinary and individualized anesthetic approach.

Case: A 33-year-old G5P0141 at 27 weeks and 4 days gestation presented to the ED with a new-onset headache and nausea following progressively worsening blood pressures (peaking at 210/130) and lower extremity edema. She had no prior history of hypertension. Her medical history was significant for Factor V Leiden deficiency with a history of DVT/PE while on oral contraceptives, pulmonary hypertension. CT imaging revealed a 2 cm right posterior parietal/superior occipital intraparenchymal hemorrhage (IPH) and a small-volume subarachnoid hemorrhage (SAH) without evidence of mass effect or midline shift. MRI findings were consistent with posterior reversible encephalopathy syndrome (PRES) and hypertensive-mediated hemorrhage. The patient was transferred to the neuro-ICU for close monitoring. She received magnesium sulfate and levetiracetam for seizure prophylaxis, betamethasone for fetal lung maturation, nicardipine infusion for blood pressure control and her anticoagulation was held. Given the maternal and fetal risks, a multidisciplinary team (obstetrics, neurology) recommended early delivery via Cesarean section.

Anesthetic Management The patient underwent a primary low transverse Cesarean section (LTCS) under a combined spinal-epidural (CSE) technique. Neuraxial anesthesia was chosen over general anesthesia to mitigate risks of airway complications, ICP fluctuations, and hemodynamic instability. She arrived to the OR neurologically intact with an infusion of nicardipine at 10mg/hr with initial BP readings at 112/56. In the seated position, a 17G Tuohy needle was used to access the epidural space with a loss of resistance syringe. A 25G pencil-tip spinal needle was inserted at L3-L4, delivering 0.75% bupivacaine (12 mg) intrathecal. Finally, a 19G epidural catheter was placed. Her highest blood pressure throughout the placement was 137/64 at the end of the procedure. Her highest blood pressure was during surgical prep 160/96 though trended down throughout the rest of the case leading to a reduction and then discontinuation of nicardipine. A live female infant was delivered in cephalic presentation with APGAR scores of 6, 7, and 8. Due to uterine atony, the patient received high-dose oxytocin and 250mcg of Carboprost IM, with satisfactory uterine tone achieved. Her intraoperative course was complicated with nausea and mild surgical discomfort both treated with IV medications. She also received 3mg morphine intra-epidural for postoperative pain. Estimated blood loss (EBL) was 500 mL, and the patient was transferred back to the ICU in stable condition infusing oxytocin.

Postoperative Course The epidural was removed 3 hours after the procedure. Postoperative pain control consisted only of acetaminophen as needed. The patient required as needed IV antihypertensives starting 12 hours after the procedure. On POD1 repeat imaging did not reveal notable change in either intracranial hemorrhage, and a heparin infusion was restarted. On POD2 her highest post op blood pressure was 181/93 and the nicardipine infusion was restarted, On POD3 she successfully switched the oral and as needed IV antihypertensives. Imaging on POD2 and 3 of the intracranial hemorrhages were also stable. On POD 5 the patient was transitioned to enoxaparin twice daily and discharged on that regimen on POD7. Outpatient follow-up includes a 1-week postop visit with Obstetrics and repeat neurologic imaging 3 months after discharge.

Discussion: This case demonstrates the complexities of managing anesthesia in high-risk obstetric patients with concurrent hypercoagulability, hypertensive disorders, and intracranial pathology. Pregnancy increases both cardiovascular demands and coagulation activation, and Factor V Leiden deficiency further exacerbates VTE risks. However, intracranial hemorrhage raises concerns for anticoagulation and neuraxial anesthesia due to the potential risk of elevated intracranial pressure and epidural hematoma 3. Neuraxial anesthesia was carefully chosen in this case due to its benefits in maintaining hemodynamic stability, avoiding ICP fluctuations, and optimizing postoperative pain control. In patients with intracranial hemorrhage, careful BP management is essential to alter a stable intracranial bleed. Postoperatively, the use of multimodal analgesia ensured effective pain control while minimizing opioid requirements, thus reducing the risk of respiratory depression and prolonged immobility. This case underscores the importance of multidisciplinary collaboration and individualized anesthetic planning to ensure maternal and fetal safety. In this instance, the neuraxial anesthetic, not without risk, provided satisfactory hemodynamic management, pain control, and was without neurologic complications.