|Year : 2019 | Volume
| Issue : 2 | Page : 99-101
Anesthetic management of an obstetric patient with idiopathic transverse myelitis: A unique approach!
Kirti N Saxena1, Amrita Kaul2, Mohammad Shakir3
1 Director Professor and Head, Department of Anaesthesiology, Maulana Azad Medical College, New Delhi, India
2 MTI fellow, Queens Hospital, Romford, England
3 Senior Resident, PGIMER and RML Hospital, New Delhi, India
|Date of Submission||23-May-2019|
|Date of Acceptance||11-Jul-2019|
|Date of Web Publication||06-Sep-2019|
Prof. Kirti N Saxena
Department of Anaesthesiology, Maulana Azad Medical College, New Delhi
Source of Support: None, Conflict of Interest: None
Transverse myelitis (TM) is a rare neurological disorder characterized by acute or subacute bilateral inflammation and myelin destruction in the spinal cord. A 14-year-old, primigravida with idiopathic TM presented to us with 38 weeks gestation for emergency cesarean section. There are potential anesthetic concerns with general anesthesia in the form of hyperkalemia following succinylcholine and delayed reversal from nondepolarizing muscle relaxants. Taking into consideration, the above-mentioned facts and level of sensory deficit of our patient; we successfully conducted the case under monitored anesthesia care with minimal analgesic support keeping our conventional anesthetic techniques as standby.
Keywords: Cesarean section, paraplegia, transverse myelitis
|How to cite this article:|
Saxena KN, Kaul A, Shakir M. Anesthetic management of an obstetric patient with idiopathic transverse myelitis: A unique approach!. J Obstet Anaesth Crit Care 2019;9:99-101
|How to cite this URL:|
Saxena KN, Kaul A, Shakir M. Anesthetic management of an obstetric patient with idiopathic transverse myelitis: A unique approach!. J Obstet Anaesth Crit Care [serial online] 2019 [cited 2019 Nov 12];9:99-101. Available from: http://www.joacc.com/text.asp?2019/9/2/99/266142
| Introduction|| |
Transverse myelitis (TM) is a rare neurological condition that involves focal inflammation of the spinal cord causing variable sensory, motor, and autonomic dysfunction. This inflammation can cause axonal demyelination. It has a peak incidence in the second and fourth decades. The effects of anesthesia on disease progression are unknown. Anesthetic management in such patients is a formidable challenge. We report the successful anesthetic management of a paraplegic parturient undergoing emergency cesarean section (CS).
| Case Report|| |
A 24-year-old, primigravida, was admitted to the emergency wing of our hospital with 38 weeks gestation in labor. She was a diagnosed case of TM for the past 1½ years. The spinal cord had been affected from C3 to T2 level of the spinal cord. She was a victim of sexual assault leading to pregnancy. She had been operated at the age of 5 years for congenital cleft palate resulting in inappropriate speech rehabilitation.
Physical examination revealed that she was able to sit only with support and she had hypoesthesia below T2 level and complete loss of sensation below T8 dermatome level. Her lower limbs were flaccid, and she had urinary and fecal incontinence. On examination, her heart rate was 82/min and blood pressure (BP) was 127/77 mmHg. Blood investigations showed hemoglobin of 14.4 g/dl, hematocrit of 33.3%, platelet count of 150,000/dl, and total leukocytic count at 11,000/dl.
The patient was on a follow-up with the neurologists, and her recent neurological examination revealed that the muscular tone was decreased in all the four limbs. Muscle power was 3/5 in the right upper limb, 2/5 in the left upper limb, and 0/5 in both the lower limbs. Bilateral deep tendon reflexes were absent in all four limbs. Bilateral abdominal reflexes were absent, and the plantar reflexes were downgoing. All the cranial nerves were normal on examination. There was no evidence of autonomic dysreflexia. Her previous neurological status 1½ years back was the same as described.
Due to the breech presentation of the fetus with cephalopelvic disproportion, emergency CS was planned by the obstetrician. On doing a complete neurological examination during the preanesthetic checkup, it was found that the patient had a complete loss of sensation below T8 level dermatome. We decided to go ahead with CS without either neuraxial blockade or general anesthesia with full preparation for inducing general anesthesia if needed. Monitoring was established with a multiparameter monitor measuring oxygen saturation, continuous electrocardiography, noninvasive BP, and end-tidal carbon dioxide by nasal prongs. Pharmacological interventions necessary to lower blood pressure in case of autonomic hyperreflexia like labetalol and glyceryltrinitrate(NTG) were kept ready.
After the establishment of an 18G intravenous (IV) line, the patient was administered IV metoclopramide and ranitidine, and surgery was allowed. The patient did not complain of pain when the Pfannenstiel incision was made. As the incision was deepened, she complained of slight discomfort. Injection ketamine 20 mg intravenously in divided doses was given with no further complaint by the patient. A healthy live neonate was delivered with Apgar scores of 9 and 10 at 1 and 5 min, respectively. 15 units of injection oxytocin were given in IV infusion after delivery of the baby.
Bowels encroached on the field during uterine closure which was managed by giving the table a head-down tilt. Injection midazolam 1 mg was given intravenously after delivery of the baby to allay the anxiety of the patient. The surgery was completed uneventfully with the patient being conscious throughout.
Estimated blood loss was 500 ml and a total of 1500 ml of IV crystalloids was given intraoperatively. The patient was hemodynamically stable throughout the surgery, with no evidence of autonomic dysreflexia. Her pulse and BP did not vary at all during surgery and postoperatively, her heart rate was 90 beats/min and BP was 112/86 mmHg. The postoperative course was uneventful, and the patient was shifted to high dependency unit. The patient was followed up for 1 week, and there was no deterioration in the patient's neurological status. She was discharged on the 8th postoperative day after stitch removal.
| Discussion|| |
Idiopathic acute TM is a rare acute inflammatory disorder of the spinal cord. Diagnostic criteria for TM include symmetrical sensory, motor, and autonomic dysfunction attributable to spinal cord inflammation either in cerebrospinal fluid or on magnetic resonance imaging scan. The most common symptoms are weakness of the limbs, paresthesia, and disturbance in bladder function with neurological deficit reaching a peak between 4 h and 21 days after the onset of symptoms. The cause of the inflammatory process remains unknown though autoimmune disorders have been postulated as the triggering mechanisms.
The natural process and of the disease varies between individual patients. It has been estimated that one-third of the patients make a good recovery, one-third are left with moderate permanent disability and one-third have a poor outcome because of severe permanent disability or death. In the acute stage of TM, the patient may present with spinal shock and hemodynamic alterations, like hypotension. In the later stages, he or she may present with autonomic dysreflexia which presents with exaggerated hypertension, reflex bradycardia, and other arrhythmias secondary to cutaneous and visceral stimuli. Autonomic dysreflexia may occur with all types of anesthesia with varying incidence, it is most commonly seen in urological surgery and least common in body surface surgery. It is important for the anesthesiologist to be aware of these complications. Vigilance is required, both during the intraoperative and postoperative periods while appropriate drugs should be at hand for emergency management of these hemodynamic alterations. Our patient did not exhibit any signs of autonomic dysreflexia in the pre-, intra- or post-operative period.
On review of the literature, we identified only eight cases of parturients with TM, four with preexisting TM,,,,, and four with acute onset TM during pregnancy. Two patients with preexisting TM were offered epidural analgesia for labor, and the other had elective CS under general anesthesia. Three acute onset TM parturient had CSs, two with general and one with epidural anesthesia and the third was not documented.
As the data available about the anesthesia of choice in such patients is limited, we felt it safe to avoid neuraxial as well as general anesthesia in this patient and conduct the surgery under monitored anesthesia care (MAC) with minimal analgesic support. In choosing our anesthetic technique, we considered the fact our patient had a total sensory deficit below T8 dermatome equivalent to an inherent pathological neuraxial blockade. Giving neuraxial anesthesia in the form of spinal or epidural in such a patient would, therefore, confer no additional benefit. In addition to this, there is some evidence to support a temporal link between neuraxial anesthesia and onset of TM. Lucas and coworkers reported the onset of TM in a 32-year-old parturient 1 month after sustaining an inadvertent dural puncture during epidural anesthesia. Jha and Kumar and Seok et al. have also attributed the onset of TM to neuraxial anesthesia in their respective reports., It has also been pointed out that regional anesthesia is contraindicated because of difficulty in evaluating neurological complications that might develop in these preexisting paraplegic patients.
On the contrary, giving general anesthesia in these patients is also controversial. Use of succinylcholine in such denervated patients such as TM can cause various complications. Denervation results in upregulation of fetal nicotinic receptors in the muscle or at neuromuscular junctions potentially causing hyperkalemia when succinylcholine used is for rapid sequence intubation in these patients. In addition to this, denervated muscles have been found to be extremely sensitive to nondepolarizing muscle relaxants. Therefore, avoidance of muscle relaxants or use of relaxants guided by neuromuscular monitoring is recommended in such patients. Weekes et al., conducted a case of CS in a parturient with preexisting TM under general anesthesia and found that the patient developed prolonged residual paralysis after a single intubating dose of rocuronium which had to be later reversed by sugammadex. The patient required ventilatory support until sugammadex was arranged.
Gutowski and Davies have described a case report of TM following general anesthesia. A 47-year-old woman developed complete TM 2 weeks after uncomplicated general anesthesia for total abdominal hysterectomy and bilateral salpingo-oophorectomy. Hambly and Martin, in their review of anesthesia on patients with spinal injuries, have conducted 103 cases under MAC and 27 under sedation. They also noted that invasive BP monitoring is not required and noninvasive BP monitoring every minute is sufficient. They further recommended that cord-injured patients may undergo multiple procedures and may regularly undergo surgeries without anesthesia. The high-risk factors for autonomic dysreflexia identified were: Lesion above T1, history of dysreflexia, and high-risk surgery (urological surgery).
Keeping in mind, the available data and the level of sensory deficit in our patient (T8), we decided to go ahead with surgery under MAC keeping conventional anesthetic techniques as standby. Although this technique has been used previously, this is probably the first cesarean delivery conducted in this manner. The use of IV ketamine as a supplemental analgesic warrants special mention. First, the dose was very low, which was enough to provide analgesia but not enough to induce anesthesia. Second, ketamine is an excellent analgesic and has been used as an infusion to give labor analgesia. Third, in low doses, it does not cause significant hemodynamic alterations.
| Conclusion|| |
Pregnant paraplegic patients present as a challenge to anesthetist, especially in rare conditions like TM. We hereby conclude that MAC with analgesic support can be used safely in TM patients undergoing CS with an uncomplicated and uneventful course of anesthesia thus avoiding the potential side effects of general and neuraxial anesthesia. However, the level of the sensory deficit should be higher than that required for the surgery.
The anesthetist has to choose wisely between the devil and the deep sea, i.e., the possibility of autonomic hyperreflexia versus the possibility of delayed reversal. The available resources help to guide the decision.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Walsh P, Grange C, Beale N. Anaesthetic management of an obstetric patient with idiopathic acute transverse myelitis. Int J Obstet Anesth 2010;19:98-101.
Balakrishnan IM, Yadav N, Singh GP. Anesthetic considerations in patients with transverse myelitis. South Afr J Anesth Analg 2013;19:323-4.
Berghella V, Spector T, Trauffer P, Johnson A. Pregnancy in patients with pre-existing transverse myelitis. Obstet Gynecol 1996;87:809-12.
Young BK, Katz M, Klein SA. Pregnancy after spinal cord injury: Altered maternal and fetal response to labor. Obstet Gynecol 1983;62:59-63.
May AE, Fombon FN, Francis S. UK registry of high-risk obstetric anaesthesia: Report on neurological disease. Int J Obstet Anesth 2008;17:31-6.
Gutowski NJ, Davies AO. Transverse myelitis following general anaesthesia. Anaesthesia 1993;48:44-5.
Hunter SA, Katz D, Riley KJ, Anderson M. Anaesthesia for an emergent caesarean section in a patient with acute transverse myelitis. J Obstet Anaesth Crit Care 2018;8:58-9. [Full text]
Thomas S, Massey S, Douglas J, Magee L, Rosengarten M. Obstetric anaesthesia and transverse myelitis. Int J Obstet Anesth 2010;19:467-8.
Lucas DN, Kennedy A, Dob DP. Dural puncture and iatrogenic pneumocephalus with subsequent transverse myelitis in a parturient. Can J Anaesth 2000;47:1103-6.
Jha S, Kumar R. Transverse myelitis following spinal anesthesia. Neurol India 2006;54:425-7.
] [Full text]
Seok JH, Lim YH, Woo SH, Yon JH. Transverse myelitis following combined spinal-epidural anesthesia. Korean J Anesthesiol 2012;63:473-4.
Weekes G, Hayes N, Bowen M. Reversal of prolonged rocuronium neuromuscular blockade with sugammadex in an obstetric patient with transverse myelitis. Int J Obstet Anesth 2010;19:333-6.
Hambly PR, Martin B. Anaesthesia for chronic spinal cord lesions. Anaesthesia 1998;53:273-89.
Joel S, Joselyn A, Cherian VT, Nandhakumar A, Raju N, Kaliaperumal I, et al.
Low-dose ketamine infusion for labor analgesia: A double-blind, randomized, placebo controlled clinical trial. Saudi J Anaesth 2014;8:6-10.