Year : 2016 | Volume
: 6 | Issue : 1 | Page : 19--21
Sterile water block labor analgesia in a parturient with ventriculoperitoneal shunt in situ
Shivali Panwar, Kirti N Saxena
Department of Anaesthesiology, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, India
Dr. Shivali Panwar
A 87, 3rd Floor, Naraina Vihar, New Delhi - 110 028
A 24-year-old woman with a ventriculoperitoneal shunt in situ presented in the anesthesia clinic at 35 weeks of gestation for labor analgesia and anesthetic options for operative delivery, if required. The patient had been diagnosed with a space-occupying lesion in the posterior fossa. This was found to be neurocysticercosis for which she underwent surgery with the placement of a right ventriculoperitoneal shunt 14 years ago. The antenatal period was uneventful and the patient went into spontaneous labor at 37 weeks of gestation. The patient was given four injections of sterile water block labor analgesia after every 3 h and underwent a normal vaginal delivery. The postnatal period was uneventful and the mother and the baby were discharged after 5 days.
|How to cite this article:|
Panwar S, Saxena KN. Sterile water block labor analgesia in a parturient with ventriculoperitoneal shunt in situ.J Obstet Anaesth Crit Care 2016;6:19-21
|How to cite this URL:|
Panwar S, Saxena KN. Sterile water block labor analgesia in a parturient with ventriculoperitoneal shunt in situ. J Obstet Anaesth Crit Care [serial online] 2016 [cited 2020 Aug 11 ];6:19-21
Available from: http://www.joacc.com/text.asp?2016/6/1/19/181067
With the advancement of medical science, there has been an increasing incidence of women with ventriculoperitoneal shunt in situ reaching the child bearing age and bearing children. Management of such patients requires a well-planned combined neurosurgical, obstetrical, and anesthesiological approach. We report here a case of a parturient with a ventriculoperitoneal shunt in situ inserted for a neurocysticercosis space-occupying lesion. Sterile water block was used for labor analgesia in the patient. The case report contains the process and outcomes.
A 24-year-old primigravida with a ventriculoperitoneal shunt in situ presented in our anesthesia clinic at 35 weeks of gestation. The patient wanted to consider anesthesia options for labor analgesia, delivery, and operative intervention if required. The patient had a history of a posterior fossa space-occupying lesion due to neurocysticercosis with associated hydrocephalus for which she was operated at 10 years of age and a right ventriculoperitoneal shunt was inserted. The patient had numerous shunt revisions and the last shunt revision was performed 1 year prior to the pregnancy. However, no treatment papers were available. Her pregnancy had been uneventful and a neurosurgical consultation was done at 28 and 33 weeks of gestation that suggested a normal functioning of the ventriculoperitoneal shunt. Spontaneous labor began at 37 weeks of gestation. Neurosurgical consultation was done again that suggested a normal shunt function. She was given sterile water block labor analgesia on the onset of labor pains. Four intradermal injections of 0.5 mL sterile water were given in the lumbosacral region. One injection was given at the posterior superior iliac spine on both the sides and the second injection was given 1 cm medial and 1 cm inferior to the first point on both the sides using an insulin needle. The injections were repeated at 3-h intervals. Visual analog scores were assessed immediately after giving the sterile water injections and at 90 min after the injection. The visual analog scores were as follows: 3, 2, 3, 3 ,3, 4, 5 at 0, 1.5, 3, 4.5, 6, 7.5, and 9 h, respectively.
The second stage of labor lasted 30 min and a mediolateral episiotomy was performed after local anesthetic infiltration. The patient had a spontaneous vaginal delivery of a live term male neonate about 9 h after the onset of labor pains. The neonate weighed 3.1 kg and had an Apgar score of 9/10. The labor and delivery were uneventful. Neurosurgeon assessed the patient postpartum and she was found to be neurologically asymptomatic. The postpartum course was unremarkable and the patient and the baby were discharged 5 days postpartum. The patient was followed up at 3 and 5 weeks postpartum and denied any symptoms suggesting deterioration of her neurological status. She was satisfied with the pain management and even requested for the same during a future pregnancy.
The obstetric management of pregnant women with extracranial shunts was first described by Monfared et al. in 1979.  Wisoff et al. studied pregnant patients with preexisting cerebrospinal fluid shunts and reported neurological complications in 76% of the patients including symptoms of raised intracranial pressure (59%), exacerbation of seizure disorder (12%), and shunt obstruction (23%) requiring surgical intervention.  Bradley et al. reported the occurrence of third trimester headaches and shunt malfunction in these patients. 
It has been proposed that an increase in the intraabdominal pressure during pregnancy may lead to a retrograde or absent flow in the shunt, causing shunt malfunction. This has led to the recommendation of a shortened second stage of labor in these patients to prevent prolonged Valsalva's maneuver and longer periods of increased intracranial pressure. 
Pregnancy in patients with cerebrospinal fluid shunts in situ should be closely monitored by a team of obstetricians and neurosurgeons for any signs of raised intracranial pressure and deterioration of neurological status. Our patient did not show any such signs. Cesarean section in these patients may lead to an intraabdominal infection and adhesion formation around the distal end of ventriculoperitoneal shunt catheter.  Patients who do not show any sign of neurological deterioration should be best managed by a spontaneous vaginal delivery if there are no obstetric contraindications for vaginal delivery.
Marx et al. reported that elevations in cerebrospinal fluid pressure during myometrial contractions in labor are related to skeletal muscle contractions occurring in response to pain.  When a patient perceives a painless uterine contraction and remains calm, a rise in pressure is not recorded. Labor analgesia is beneficial for these patients because it avoids increases in the intracranial pressure that would be detrimental for such patients. However, it is optional and, hence, should be as safe as possible for the patient. In this case we opted for labor analgesia because the patient demanded it and because of the ventriculoperitoneal shunt in situ. We had regional anesthesia, intravenous opioids analgesia, and conservative techniques of labor analgesia as options available to us, but the safest technique was chosen.
There have been published reports of the use of neuraxial anesthesia in patients with cerebrospinal fluid shunts in situ. , However, it may be associated with complications such as bacterial meningitis and elevation of intracranial pressures after large doses of epidural drug administration. Epidural analgesia is not a simple procedure and is associated with complications such as technical difficulties, dural puncture, vascular placement, and hypotension. Dural puncture with large-bore epidural needle can cause alteration of differential pressure and brainstem herniation in patients with intracranial hypertension.  For the reasons mentioned above, we avoided the use of epidural analgesia in this patient.
Intravenous opioids are known to cause respiratory depression and hypercarbia and hypoxia that can lead to elevation in intracranial pressure. Opioids can alter the sensorium as well, making monitoring of neurological status more difficult, and, hence, were avoided. Conservative labor analgesia techniques were the best option for this patient. We adopted sterile water block labor analgesia as it is effective, inexpensive, easy to administer, and is free from any major side effect. The effect begins quickly and analgesia lasts for about 2-3 h. 
To the best of our knowledge, this is the first reported case in which sterile water block labor analgesia has been administered to a parturient with ventriculoperitoneal shunt in situ.
Authors have reported the efficacy of intradermal sterile water injections for relieving labor pain. , It has been proposed to work by either the gate control theory of pain or the release of endogenous endorphins. 
The corpus uteri and cervix are supplied by afferent neurons ending in the dorsal horns of spinal segments T10-L1. Referred pain from these nerve roots can be felt over the lower back and sacrum or over the lower abdomen and pubis. Sterile water block labor analgesia involves injecting intradermal sterile water at four different points over the sacrum. These injections trigger the firing of C fibers along with A delta fibers that are normally associated with somatic pain. The somatic pain input from A delta fibers dominates the visceral pain input from C fibers and, hence, the visceral pain is barely noticed. This hypothesis is based on the gate control theory of pain. ,
Our patient remained calm during the labor and there were no associated signs of raised intracranial pressure during the intrapartum period. She was satisfied with the labor analgesia and even requested for the same in the case of a second pregnancy.
We strongly advocate the use of sterile water block labor analgesia for managing such patients as it avoids the detrimental effects of regional anesthesia and is free of any major side effect.
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Conflicts of interest
There are no conflicts of interest.
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