Anesthesia Management on 29 Weeks Pregnant Women with Intracranial SOL, Invasive Carcinoma Mammae and Bronchopneumoniaes

Background: Pregnancy gives whole different challenge for anesthesiologist because of we handle two lives at once. Brain tumor in pregnancy correlated with maternal mortality, prematurity and intra uterine growth restriction (IUGR). It makes delivery time, what kind of anesthesia technique we used choosen by the situation. Case: We report a case of anesthesia technique using general anesthesia (GA) to accommodate sectio cesarean transperitoneal profunda (SCTP) in a 29 weeks pregnancy age, G1P0A0 female patient, ASA IIIE with intracranial SOL suspect cerebri abscess multiple dd/ tuberculoma, invasive mammae carcinoma, and bronchopneumoniae. Disscussion: Space occupied lesion (SOL) is a lesion in intracranial space especially give effect to brain. In our patient with SOL from cerebri abscess multiple dd/ tuberculoma. It caused intracranial pressure increase and also spastic hemiparese dextra. Pregnancy termination was done depends on 29 weeks pregnancy with SOL in this patient. We used GA for cesarean section (CS). Anesthesia technique will be considered successful if new born baby activity, pulse, grimace, appearance, and respiration (APGAR) is good. Conclusion: Female G1P0A0, 32 years old, 29 weeks pregnancy age, single intrauterine fetus with intracranial SOL suspect cerebri abscess multiple dd/ tuberculoma, invasive mammae carcinoma, and bronchopneumoniae was consulted by Obstetrician to Anestesiologist to do CS with GA. During anesthesia and surgery, there was no complication. In this case, termination was done for baby and mother’s well being.


INTRODUCTION
Pregnancy has an impact on anatomical, physiological, pharmacological and psychological changes in the mother so that caesarean section in pregnant women is a challenge for anesthesiology specialists, because of considerations for the safety of the mother and baby. 1 Brain tumors in pregnancy are correlated with increased maternal mortality, premature birth and intrauterine growth restriction (IUGR). 2 The presence of a brain tumor in pregnancy will influence the determination of the time of delivery, the type and technique of anesthesia to be used.About 75% of intracranial tumors occur in women of reproductive age and during pregnancy.Tumor enlargement during pregnancy is related to fluid retention, accumulation of hormonal changes, swelling of blood vessels, and the presence of growth hormone receptors which cause progression of neurological symptoms during pregnancy and post-partum remission. 3thers with intracranial lesions are often assumed to have increased intracranial pressure, even in the absence of clinical and radiographic signs. 2 To care for these women and determine which of them can safely undergo spinal or epidural analgesia or anesthesia we must understand the factors involved.contribute to clinically significant shifts in brain tissue (i.e.brain herniation), such as increased intracranial pressure (ICP), brain edema, or hydrocephalus.The anesthesiologist can then effectively weigh the relative risks and benefits of neuraxial anesthesia. 4tracranial space occupying lesion (SOL) Space occupying lesion (SOL) is a generalization of lesions in the intracranial space, especially those affecting the brain.SOL is caused by the presence of a new mass in the carnium which is generally associated with malignancy but can also be caused by other pathological conditions such as brain abscess or hematoma. 4This mass produces consequences in the form of increased intracranial pressure because the cranium is a space with a fixed volume. 1,2,3gure 1.Schematic of the spatial compression process with a perifocal effect that causes compression of brain tissue and midline shift.

Intracranial anatomy
The brain consists of 3 main structural divisions: the cerebrum, brainstem, and cerebellum (Figure 2).At the base of the brain is the brainstem, which extends from the upper cervical spinal cord to the diencephalon of the cerebrum.The brainstem is divided into the medulla, pons, and midbrain.Behind the brain stem lies the cerebellum.The meninges consist of 3 layers of tissue that cover the brain and spinal cord: the pia, arachnoid, and dura mater (Figure 3).The pia together with the arachnoid are referred to as leptomeninges, while the dura is referred to as pachymeninx. 5e cellular structure of the brain mainly consists of neurons and their supporting cells, which are broadly called glial cells.The 3 main types of glial cells are astrocytes, oligodendrocytes, and microglia.These glial cells can give rise to glial tumors, such asastrocytoma, oligodendroglioma, and glioblastoma, which are among the most common primary brain tumors. 5 The Monro-Kellie doctrine is currently used as a reference in measuring intracranial pressure.Intracranial content consists of brain tissue, blood and cerebrospinal fluid. 1 If in a situation there is an increase in intracranial mass, the initial compensation is a decrease in the volume of venous blood and cerebrospinal fluid (CSF).The next compensation is that the CSF will be pushed through the foramen magnum towards the spinal subarachnoid cavity.Clinical features of intracranial SOL The common manifestation of SOL is headache and is the worst symptom in about half of the patients.Headache is a dull, constant pain, sometimes throbbing. 6agnosis of intracranial SOL The diagnosis of SOL is made with an appropriate history, relevant examination findings, and appropriate supporting examinations.Advances in cranial imaging have made the detection of intracranial lesions relatively accurate and allowed us to focus on the etiology of the lesions occupying this space. 6Xrays of the skull and brain provide only limited insight into brain tumors.Computerized tomography (CT) scan of the head or magnetic resonance imaging (MRI) of the head to confirm the presence of a tumor and the location of the tumor.MRI is more sensitive for detecting small metastatic tumors.Imaging is important to determine whether it is a true tumor or shows the appearance of an abscess.An abscess is differentiated from a tumor by the presence of enhancement on a CT scan with contrast.It may be difficult to differentiate pyogenic brain abscess from necrotic glioblastoma and cystic metastases with conventional MRI because all can appear as rim-enhancing masses with prominent perifocal edema. 7,8Diffusion-weighted imaging (DWI) and diffusion-tensor imaging (DTI) are measuring water diffusivity complements the role of conventional MR in the differentiation of abscesses from glioblastoma and necrotic metastases. 6,7,9Management of intracranial SOL Some intracranial tumors are not amenable to surgical resection, or the characteristics of such lesions make them more appropriate to treat with radiation therapy.For example, if the lesion is small, or is in several parts of the brain, or within an area of the brain where surgical resection could potentially cause more harm than good, radiation therapy is a consideration.Consultation with a radiation oncologist can provide patients with a variety of radiotherapy treatment options to target the tumor.For example, patients with multiple diffuse metastases too numerous for surgical resection may benefit from whole brain radiation therapy, whereas patients with single small radiosensitive lesions may benefit from stereotactic radiosurgery.Patients who also undergo surgical resection of their intracranial tumors often receive radiation therapy to the surgical resection bed. 8emotherapy is also used as a therapy for some tumors.A consultation with a neuro-oncologist should be undertaken, and various chemotherapy regimens should be discussed.Traditionally, the use of chemotherapy in the brain has been limited, because the nature of the blood-brain barrier limits the efficacy of drugs that cross the barrier. 8rebral abscesses can be considered for treatment with a medical or surgical approach.Medical management may be considered for small, deep abscesses (less than 2 cm), cases of meningitis, and certain other cases.10 Typically, a combination of medical and surgical approaches is considered.The choice of antibiotic regimen should be made judiciously based on the microorganisms isolated from the blood or CSF.Certain antibiotics cannot cross the blood-brain barrier and are not useful in treating brain abscesses; These antibiotics include first generation cephalosporins, aminoglycosides, and tetracyclines.Steroids may be considered in selected cases, especially to reduce mass effect and improve antibiotic penetration and cerebral edema. 11Surgical approaches have an important role in the management of brain abscesses.The choice of procedure depends on the operator's skills and preferences.Approaches include ultrasound, or CTguided needle aspiration via stereotactic Volume 16, Nomor 1, Tahun 2024 procedures, bur holes, and craniotomy for localized multiple abscesses.Intravenous or intrathecal agents against certain microorganisms are considered with surgical therapy. 12esthetic management in SOL cases Space occupying lesion (SOL) is one of the indications for surgery in the supratentorial area.Preoperative management in supratentorial surgery includes evaluating the location and size of the lesion, surgical access, patient positioning, estimated blood loss, and changes in intracranial pressure (ICP). 10,11Examination of the patient's neurological status including level of consciousness using the Glasgow Coma Scale (GCS), signs specific focal neurologic examination, and review of the patient for other diseases, are also performed before surgery.Anesthetic premedication in the form of benzodiazepines can be given to patients who are anxious and do not have signs of increased ICP. 13 Other treatments being given such as corticosteroids and anticonvulsants must be continued until the time of surgery. 14e target of intraoperative management is a smooth induction, stable hemodynamics, as well as the duration and smooth emergence of anesthesia to be able to carry out an initial neurological examination. 15Induction and intubation can cause intracranial hypertension, therefore intravenous anesthesia, generally using propofol or thiopental, plus administration of intravenous lidocaine, and avoiding administration of nitric oxide can be done to prevent an increase in ICP during induction and intubation.Standard monitoring is performed on patients during induction of anesthesia.Core temperature is also monitored and a urinary catheter is inserted, especially if hyperosmolar agents are administered at the time of surgery. 16re should be taken to minimize Valsalva during rapid sequence induction and the emergence of general anesthesia, although blunting airway reflexes in these patients may further increase their risk of pregnancy-related aspiration.Strategies to blunt the sympathetic response to intubation include combining induction agents with opioids (eg, fentanyl 2-5 g/kg bolus or remifentanil 1 g/kg over 1 minute) or labetolol in 5 mg increments. 17Some experts recommend replacing succinylcholine, which theoretically can cause a temporary increase in ICP due to contraction of abdominal and chest muscles, with a nondepolarizing muscle relaxant (eg, rocuronium 1.2 mg/kg) for a rapid induction sequence. 18,19While hyperventilation is beneficial for mothers with lowering ICP and maximizing cerebral blood flow in patients with elevated ICP, it may harm the fetus by decreasing placental blood flow. 17To balance fetal and maternal cerebral perfusion, the recommendation is to maintain maternal PaCO2 approximately 25-30 mmHg and maternal blood pressure close to baseline. 20rgery for intracranial tumors requires several positions, such as supine, prone, lateral and sitting.An elevated patient position of approximately 30 degrees with the head straight is recommended to avoid increasing ICP by facilitating venous drainage.However, in some cases, a flexed neck position is required for surgical access even though it can cause airway obstruction and obstruction of cerebral venous return resulting in intraoperative cerebral edema. 16,17olume 16, Nomor 1, Tahun 2024

CASE
The patient with the name Mrs. RW, age 32 years, female, medical record number C924583, was admitted to the hospital on April 6 2022.
The patient has no history of asthma, hypertension, diabetes mellitus, heart disease.The patient has a history of sedation or surgery on the left mammary gland, GA, post surgery is good.The patient last ate 6 hours before the procedure.
The patient has no fever or runny nose, the patient has shortness of breath.Coughing with phlegm starting from 1 month of pregnancy, shortness of breath, active fetal movements are felt.The patient experiences weakness in the right limb, the right hand can only shift.The patient can sit with assistance.The patient can sleep on his back with 2 pillows, or 45 degrees.From the BGA examination (13/04/22 at 02.33) the patient found, pH 7,464, FiO2 32.0, PCO2 41.2, PO2 142.1, HCO3 28.9, BE (B) 4.7, SO2c 98.9, A-aDO2 36.2,PFR 444.COVID-19 antigen swab examination (12/04/2022) showed negative results.

From chest
x-ray examination (01/04/2022), it was found that the cast was not enlarged, opacity in the right lower middle field→DD/mass, loculated pleural effusion, infiltrate in the lower midfield of the left lung→suspect bronchopneumonia.
From the Plain Head MRI examination (31/03/2022), the results showed multiple inhomogeneous solid masses with cystic parts and intratumoral hemorrhage in the gray-white matter of the right left frontal lobe, left parietal, right parietooccipital, left cerebellum (largest size ± AP 3.6 x CC 4.6 x LL 4.6 cm on the right parietooccipital) accompanied by vasogenic edema in the right left frontal lobe, right temporal, right left parietal, right occipital, body corpus callosum, left cerebellum which presses on the right lateral ventricle and causes midline shifting to the left (± 0, 6cm)→DD/tuberculoma, abscess.There are signs of increased intracranial pressure on 3D TOF: L-ACA segment A1 appears small.Patient assessment included G1P0A0, 32 years old, 29 weeks 3 days pregnant, 1 live fetus intrauterine, intracranial SOL suspected of multiple cerebral abscesses and tuberculoma, invasive mammary carcinoma, progressive chronic cephalgia, spastic dextral hemiparesis, bronchopneumonia, observation of improving fever.The patient's plan is SCTP with GA ASA IIIE, postoperative ICU backup, 1 PRC blood effort from the operator, IVFD NaCL 0.9% 20 tpm, maintain O2 NC 3-4 lpm. Intraoperative:

DISCUSSION
Space occupying lesion (SOL) is a generalization of lesions in the intracranial space, especially those affecting the brain.In this patient there was SOL originating from multiple cerebral abscesses with a differential diagnosis of tuberculoma.This mass produces consequences in the form of increased intracranial pressure because the cranium is a space with a fixed volume.In this patient there were neurological manifestations due to SOL, namely chronic progressive cephalgia accompanied by spastic right hemiparesis.Considering the condition of the patient who was 29 weeks pregnant accompanied by the presence of SOL, termination of pregnancy was carried out.SOL in pregnant patients requires comprehensive management which includes several departments such as nerves, obstetrics, and anesthesiologists.
Comprehensive multidisciplinary management is not only in establishing the diagnosis, but also in perioperative management because it requires careful planning to balance the welfare of the mother and fetus.This requires modification of neuroanesthetic and obstetric practices that often have competing clinical goals to achieve optimal maternal and fetal safety.
Termination of pregnancy in this patient was carried out by caesarean section (CS) with general anesthesia (GA).Care should be taken to minimize Valsalva during rapid sequence induction and the emergence of general anesthesia, although blunting airway reflexes in these patients may further increase their risk of pregnancy-related aspiration.Strategies to blunt the sympathetic response to intubation include combining induction agents with opioids or labetolol.The success of the anesthesia method is determined by assessing the newborn's APGAR score.The infant may be affected directly by transplacental drug transfer or indirectly by changes in fetal-placental perfusion, or both.The risk of immediate effects from placental transfer is greatest with general anesthesia, as maternal drug exposure is greater for CS delivery.