200
International Journal of Obstetric Anesthesia
is likely but the condition could recur in subsequent pregnancies. S. King, J. Broadway, R. Morris, K. Turner Department of Anaesthetics Ipswich Hospital, Ipswich, UK
Reference 1. Ch’ng CL, Morgan M, Hainsworth I, Kingham JG. Prospective study of liver dysfunction in pregnancy in Southwest Wales. Gut 2002;51:876–80. 0959-289X/$ - see front matter c 2015 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijoa.2015.02.005
Intrathecal haematoma: a rare cause of back pain following epidural blood patch A 27-year-old woman, with a body mass index of 33 kg/m2 experienced severe lumbar back pain and radicular symptoms following an epidural blood patch. The initially unrecognised dural puncture occurred during attempted epidural placement in labour. The difficult procedure was abandoned as delivery was imminent. The following day the parturient developed symptoms consistent with a post-dural puncture headache (PDPH). Epidural blood patch (EBP) was performed on day two with symptomatic relief. This was repeated successfully for symptom recurrence on day five. Five days later she developed lower back pain that radiated to the left leg, with no other adverse features, which worsened over the following two days. Urgent magnetic resonance imaging demonstrated a intrathecal haematoma extending from L5 to the sacral canal. Conservative management with gabapentin was undertaken after neurosurgical consultation. It was felt that symptoms likely represented local irritation. Improvement occurred within four days and resolution within 10 days. It was inferred that this followed reabsorption of the intrathecal blood. Epidural blood patching is perceived as being a relatively low-risk procedure. The most common adverse effect is lumbar back pain. More significant reported complications include radicular pain, lumbovertebral syndrome, acute paraesthesia, acute neurological or mental deterioration, bradycardia, visual loss, arachnoiditis and symptomatic haematoma.1 We are aware of only two cases of intrathecal haematoma reported within obstetric practice,1,2 and two cases of subdural haematoma.3,4 One subarachnoid haematoma likely occurred after direct injection of blood through a misplaced catheter.1 To our knowledge, this case represents
only the second reported obstetric case of intrathecal haematoma post EBP for PDPH performed using standard technique and the first reported in the obstetric literature. Interestingly, these cases were managed conservatively. Only the patient who underwent EBP via the catheter suffered ongoing neuropathic symptoms. This is in comparison to many intrathecal haematomas reported post primary neuraxial anaesthesia where early surgical involvement has not always prevented permanent injury. While we would not advocate any sense of complacency when it comes to the potential for permanent harm when complications of EBP are suspected, and support rapid investigation and neurosurgical consultation in all cases, we add our case to the very limited reports available so that it may be used to offer reassurance to both anaesthetist and patient while awaiting symptom resolution during what is a stressful time in a mother’s life. L. Hudman Department of Anaesthesia Glasgow Royal Infirmary, Glasgow, UK G. Rappai Department of Anaesthesia Golden Jubilee National Hospital, Clydebank, UK F. Bryden Department of Anaesthesia, Glasgow Royal Infirmary Glasgow, UK
References 1. Kalina P, Craigo P, Weingarten T. Intrathecal injection of epidural blood patch: A case report and review of the literature. Emerg Radiol 2004;11:56–9. 2. Aldrete JA, Brown TL. Intrathecal hematoma and arachnoiditis after prophylactic blood patch through a catheter. Anesth Analg 1997;84:233–4. 3. Riley CA, Spiegel JE. Complications following large volume epidural blood patches for postdural puncture headache. Lumbar subdural haematoma and arachnoiditis: Initial cause or final effect? J Clin Anest 2009;21:355–9. 4. Verduzco LA, Atlas SW, Riley ET. Subdural haematoma after an epidural blood patch. Int J Obstet Anesth 2012;21:189–92. 0959-289X/$ - see front matter
c 2015 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2015.02.003
Psychogenic paresis following neuraxial anaesthesia in a complex obstetric case A 22-year-old parturient presented with motor and sensory dysfunction in both lower limbs, one week after undergoing obstetric anaesthetic care in labour. The
International Journal of Obstetric Anesthesia patient had a complex past medical history of brittle asthma, with several previous critical-care admissions and multiple exacerbations during pregnancy. At 30 weeks of gestation, she was admitted to the general high-dependency unit with a further asthma exacerbation. Whilst there, she developed premature labour and was transferred to the delivery suite. Over the forthcoming hours attempts were made to provide pain relief in labour, given her ongoing impaired respiratory function. Three epidurals were sited, all without difficulty but all failing to provide an adequate block. She subsequently underwent a category 3 caesarean section for failure to progress, performed uneventfully under general anaesthesia. She improved postoperatively and was discharged, with her baby doing well in the neonatal intensive care unit. The patient recovered uneventfully at home until postoperative day seven, when she awoke with flu-like symptoms, back pain and an inability to move or feel her legs. She was readmitted to hospital and commenced on antibiotics for a presumed epidural abscess. An urgent magnetic resonance imaging (MRI) scan showed no evidence of haematoma or abscess, and she was transferred to the care of a neurologist for further investigation. Subsequent repeat MRI scans and lumbar puncture were normal. However, her symptoms worsened with increased lower limb tone, loss of proprioception and development of faecal incontinence. Two weeks later, nerve conduction studies were performed which were normal, resulting in a diagnosis of functional paresis. Following neuropsychologist involvement she gradually improved and was discharged six weeks later with resolution of symptoms. Psychogenic paresis is a rare psychiatric conversion disorder whereby neurological symptoms develop that cannot be explained by an underlying organic condition.1 It is particularly rare within obstetric anaesthesia.2,3 Preceding stressors typically exist indicating a psychological cause; however, symptoms are not intentionally produced, thereby differentiating it from a factitious condition. It occurs more frequently in females, early adulthood and those of lower socioeconomic status, and patients commonly exhibit an apparent lack of concern with their symptoms – ‘‘la belle indiffe´rence’’. Management consists of psychotherapy, addressing any underlying depression or anxiety, and physiotherapy. Early diagnosis and treatment results in a better prognosis, although approximately one in five still relapse within one year. Although rare, and a diagnosis of exclusion, it should be considered in complex cases such as this where neurological symptoms and signs develop in the absence of spinal cord pathology. C. Bryant Department of Anaesthetics Gloucester Royal Hospital, Gloucester, UK
201 N. Wharton, R. Alexander Department of Anaesthetics Bristol Royal Infirmary, Bristol, UK
References 1. American Psychiatric Association, editor. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000. p. 492–7. 2. Nguyen J, Abola R, Schabel J. Recurrent psychogenic paresis after dural puncture in a parturient. Int J Obstet Anesth 2013;22:160–3. 3. Sleth JC. Hysterical conversion mimicking acute paraplegia after spinal anaesthesia. Int J Obstet Anesth 2010;19:126–7. 0959-289X/$ - see front matter c 2015 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijoa.2015.02.005
Management of a parturient with a retrosternal goitre and tracheal compression There is limited information available to guide the management of pregnant women at risk of airway obstruction. We present the case of a pregnant woman with a large thyroid goitre causing tracheal compression. A 36 year-old multiparous woman was diagnosed with a benign multi-nodular goitre but conceived before proceeding to surgery. A computed tomography (CT) scan at 24 weeks of gestation showed an increase in goitre size with retrosternal extension; the tracheal cross-sectional area at C7 had almost halved from 85 mm2 to 45 mm2 (Fig. 1). She remained euthyroid. Early in the third trimester, she was twice admitted to hospital with stridor associated with viral upper respiratory tract infection. A multidisciplinary meeting was held at 29 weeks. While no further increase in goitre size was expected, the risk of acute obstruction secondary to intercurrent illness or nodule rupture remained. Elective caesarean section (CS) was scheduled at 32 weeks to allow fetal maturation with a plan for total thyroidectomy four weeks later.
Fig. 1
Computed tomography scan at level of C7
International Journal of Obstetric Anesthesia
is likely but the condition could recur in subsequent pregnancies. S. King, J. Broadway, R. Morris, K. Turner Department of Anaesthetics Ipswich Hospital, Ipswich, UK
Reference 1. Ch’ng CL, Morgan M, Hainsworth I, Kingham JG. Prospective study of liver dysfunction in pregnancy in Southwest Wales. Gut 2002;51:876–80. 0959-289X/$ - see front matter c 2015 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijoa.2015.02.005
Intrathecal haematoma: a rare cause of back pain following epidural blood patch A 27-year-old woman, with a body mass index of 33 kg/m2 experienced severe lumbar back pain and radicular symptoms following an epidural blood patch. The initially unrecognised dural puncture occurred during attempted epidural placement in labour. The difficult procedure was abandoned as delivery was imminent. The following day the parturient developed symptoms consistent with a post-dural puncture headache (PDPH). Epidural blood patch (EBP) was performed on day two with symptomatic relief. This was repeated successfully for symptom recurrence on day five. Five days later she developed lower back pain that radiated to the left leg, with no other adverse features, which worsened over the following two days. Urgent magnetic resonance imaging demonstrated a intrathecal haematoma extending from L5 to the sacral canal. Conservative management with gabapentin was undertaken after neurosurgical consultation. It was felt that symptoms likely represented local irritation. Improvement occurred within four days and resolution within 10 days. It was inferred that this followed reabsorption of the intrathecal blood. Epidural blood patching is perceived as being a relatively low-risk procedure. The most common adverse effect is lumbar back pain. More significant reported complications include radicular pain, lumbovertebral syndrome, acute paraesthesia, acute neurological or mental deterioration, bradycardia, visual loss, arachnoiditis and symptomatic haematoma.1 We are aware of only two cases of intrathecal haematoma reported within obstetric practice,1,2 and two cases of subdural haematoma.3,4 One subarachnoid haematoma likely occurred after direct injection of blood through a misplaced catheter.1 To our knowledge, this case represents
only the second reported obstetric case of intrathecal haematoma post EBP for PDPH performed using standard technique and the first reported in the obstetric literature. Interestingly, these cases were managed conservatively. Only the patient who underwent EBP via the catheter suffered ongoing neuropathic symptoms. This is in comparison to many intrathecal haematomas reported post primary neuraxial anaesthesia where early surgical involvement has not always prevented permanent injury. While we would not advocate any sense of complacency when it comes to the potential for permanent harm when complications of EBP are suspected, and support rapid investigation and neurosurgical consultation in all cases, we add our case to the very limited reports available so that it may be used to offer reassurance to both anaesthetist and patient while awaiting symptom resolution during what is a stressful time in a mother’s life. L. Hudman Department of Anaesthesia Glasgow Royal Infirmary, Glasgow, UK G. Rappai Department of Anaesthesia Golden Jubilee National Hospital, Clydebank, UK F. Bryden Department of Anaesthesia, Glasgow Royal Infirmary Glasgow, UK
References 1. Kalina P, Craigo P, Weingarten T. Intrathecal injection of epidural blood patch: A case report and review of the literature. Emerg Radiol 2004;11:56–9. 2. Aldrete JA, Brown TL. Intrathecal hematoma and arachnoiditis after prophylactic blood patch through a catheter. Anesth Analg 1997;84:233–4. 3. Riley CA, Spiegel JE. Complications following large volume epidural blood patches for postdural puncture headache. Lumbar subdural haematoma and arachnoiditis: Initial cause or final effect? J Clin Anest 2009;21:355–9. 4. Verduzco LA, Atlas SW, Riley ET. Subdural haematoma after an epidural blood patch. Int J Obstet Anesth 2012;21:189–92. 0959-289X/$ - see front matter
c 2015 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2015.02.003
Psychogenic paresis following neuraxial anaesthesia in a complex obstetric case A 22-year-old parturient presented with motor and sensory dysfunction in both lower limbs, one week after undergoing obstetric anaesthetic care in labour. The
International Journal of Obstetric Anesthesia patient had a complex past medical history of brittle asthma, with several previous critical-care admissions and multiple exacerbations during pregnancy. At 30 weeks of gestation, she was admitted to the general high-dependency unit with a further asthma exacerbation. Whilst there, she developed premature labour and was transferred to the delivery suite. Over the forthcoming hours attempts were made to provide pain relief in labour, given her ongoing impaired respiratory function. Three epidurals were sited, all without difficulty but all failing to provide an adequate block. She subsequently underwent a category 3 caesarean section for failure to progress, performed uneventfully under general anaesthesia. She improved postoperatively and was discharged, with her baby doing well in the neonatal intensive care unit. The patient recovered uneventfully at home until postoperative day seven, when she awoke with flu-like symptoms, back pain and an inability to move or feel her legs. She was readmitted to hospital and commenced on antibiotics for a presumed epidural abscess. An urgent magnetic resonance imaging (MRI) scan showed no evidence of haematoma or abscess, and she was transferred to the care of a neurologist for further investigation. Subsequent repeat MRI scans and lumbar puncture were normal. However, her symptoms worsened with increased lower limb tone, loss of proprioception and development of faecal incontinence. Two weeks later, nerve conduction studies were performed which were normal, resulting in a diagnosis of functional paresis. Following neuropsychologist involvement she gradually improved and was discharged six weeks later with resolution of symptoms. Psychogenic paresis is a rare psychiatric conversion disorder whereby neurological symptoms develop that cannot be explained by an underlying organic condition.1 It is particularly rare within obstetric anaesthesia.2,3 Preceding stressors typically exist indicating a psychological cause; however, symptoms are not intentionally produced, thereby differentiating it from a factitious condition. It occurs more frequently in females, early adulthood and those of lower socioeconomic status, and patients commonly exhibit an apparent lack of concern with their symptoms – ‘‘la belle indiffe´rence’’. Management consists of psychotherapy, addressing any underlying depression or anxiety, and physiotherapy. Early diagnosis and treatment results in a better prognosis, although approximately one in five still relapse within one year. Although rare, and a diagnosis of exclusion, it should be considered in complex cases such as this where neurological symptoms and signs develop in the absence of spinal cord pathology. C. Bryant Department of Anaesthetics Gloucester Royal Hospital, Gloucester, UK
201 N. Wharton, R. Alexander Department of Anaesthetics Bristol Royal Infirmary, Bristol, UK
References 1. American Psychiatric Association, editor. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000. p. 492–7. 2. Nguyen J, Abola R, Schabel J. Recurrent psychogenic paresis after dural puncture in a parturient. Int J Obstet Anesth 2013;22:160–3. 3. Sleth JC. Hysterical conversion mimicking acute paraplegia after spinal anaesthesia. Int J Obstet Anesth 2010;19:126–7. 0959-289X/$ - see front matter c 2015 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijoa.2015.02.005
Management of a parturient with a retrosternal goitre and tracheal compression There is limited information available to guide the management of pregnant women at risk of airway obstruction. We present the case of a pregnant woman with a large thyroid goitre causing tracheal compression. A 36 year-old multiparous woman was diagnosed with a benign multi-nodular goitre but conceived before proceeding to surgery. A computed tomography (CT) scan at 24 weeks of gestation showed an increase in goitre size with retrosternal extension; the tracheal cross-sectional area at C7 had almost halved from 85 mm2 to 45 mm2 (Fig. 1). She remained euthyroid. Early in the third trimester, she was twice admitted to hospital with stridor associated with viral upper respiratory tract infection. A multidisciplinary meeting was held at 29 weeks. While no further increase in goitre size was expected, the risk of acute obstruction secondary to intercurrent illness or nodule rupture remained. Elective caesarean section (CS) was scheduled at 32 weeks to allow fetal maturation with a plan for total thyroidectomy four weeks later.
Fig. 1
Computed tomography scan at level of C7
