Year : 2016 | Volume
: 6 | Issue : 1 | Page : 38--40
Blame it on anesthesia: A clinical case of postpartum complication after the intervention of anesthesiology for labor analgesia
Samuel Ramos, Paulo Muchacho, Hélder Cavaco, Célia Xavier
Department of Anesthesiology, Hospital de Santa Maria, Ramada, Portugal
Dr. Samuel Ramos
Avenida Amália Rodrigues, n.°10, 3°A, Ramada - 2620-531
Anesthesiologists are often prevented from performing a follow-up of clinical cases due to the specific characteristics of their activity and may be blamed for complications not directly related to their interventions. Moreover, prudent strategies for communicating the diagnostic hypotheses are not always used, with relevant repercussions on the responsibilities imputed. Acute urinary retention (AUR) in pregnant women is a known complication of the postpartum period. Studies have reported the association between symptomatic AUR and neuraxial anesthesia/analgesia, instrumental labor, nulliparity, and episiotomy and have stated them to be the main risk factors of AUR. Severe neurological lesions resulting from the neuraxial approach, which is the main anesthesiologist intervention, is rare (0.0012-0.004%). In this study, we describe a case of a nulliparous pregnant admitted to the Obstetrics Department who developed AUR. We suggest that there must be a cautious attitude in the practice of medicine when allocating responsibilities, particularly in clinical syndromes that are not yet well-explained.
|How to cite this article:|
Ramos S, Muchacho P, Cavaco H, Xavier C. Blame it on anesthesia: A clinical case of postpartum complication after the intervention of anesthesiology for labor analgesia.J Obstet Anaesth Crit Care 2016;6:38-40
|How to cite this URL:|
Ramos S, Muchacho P, Cavaco H, Xavier C. Blame it on anesthesia: A clinical case of postpartum complication after the intervention of anesthesiology for labor analgesia. J Obstet Anaesth Crit Care [serial online] 2016 [cited 2020 Aug 6 ];6:38-40
Available from: http://www.joacc.com/text.asp?2016/6/1/38/181078
Anesthesiologists are often recommended to avoid performing the follow-up of all clinical cases due to the specific characteristics of their activities and the multitude of acts in which they are involved.
They are blamed for complications in clinical cases without any previous thorough diagnostic investigation; such complications are often not directly related to their interventions. Similarly, prudent strategies for communicating the diagnostic hypotheses are not always used; this often has relevant repercussions in terms of the responsibilities given to them.
There are two categories of postpartum neurologic injury:
Obstetric palsies (due to compression or stretching during labor) and Other lesions, which include those closely related to the neuraxial approach. 
The incidence of postpartum obstetric neuropathy is about 1%. However, the emergence of severe neurological lesions resulting from the neuraxial approach is rare (0.0012-0.004%). ,
In the literature, a great variability in the incidence of urinary retention has been reported based on the definitions used.  Postpartum urinary retention physiopathology, although not well-clarified, seems to be related to physiological, neurological, and mechanical factors. During the expulsion period, either compression or stretching of the pelvic nerves (particularly the pudendal nerve) may occur, resulting in changes in the parasympathetic afferents, which are fundamental at the beginning of the micturition reflex. Systematic reviews and meta-analysis have consistently shown the association between symptomatic acute urinary retention (AUR) and neuraxial anesthesia/analgesia, instrumental labor, nulliparity, and episiotomy, thus positing them as the main risk factors. 
Through the clinical case, we intend to address the AUR complication in pregnant women. This may contribute to a better understanding of anesthesiologists (as well as the medical community) and address the issue of medical errors and conflicts between medical specialties.
A full-term nulliparous pregnant 32-year-old [American Society of Anesthesiologists (ASA) 1] with premature rupture of the amniotic membrane in the latent phase of the first stage of labor was admitted to the Obstetrics Department of the North Lisbon Hospital Centre. The patient had no relevant medical background and no ambulatory medication. Normal physical examination, including spine curvature or palpation of the interspinous spaces, was undertaken.
The anesthesia team, consisting of a 2nd year anesthesiology resident and an attending anesthesiologist, was contacted when the patient was already in the active phase of labor with 7-cm dilation of the cervix (3 h after admission). The team used neuraxial analgesia with a combined technique. First, both of them attempted to perform the technique. After unsuccessful attempts, the senior anesthesiologist performed spinal analgesia through a paramedian approach (L4-L5 level), along with the administration of 1 mL of ropivacaine 0.2% (2 mg) and sufentanil 7.5 mcg.
It was a dystocic labor with forceps without apparent immediate complications. The newborn male weighed 3.120 kg. After the first 24 h, the urinary catheter was removed with spontaneous urination. Around 48 h in the postpartum period, the patient presented with a thrombosed hemorrhoidal plexus of great dimensions and had to undergo thrombectomy under local anesthesia, which delayed her hospital discharge. At 72 h, the patient started a clinical condition consistent with AUR.
Upon clinical evaluation of the condition, the obstetricians suggested that the clinical condition was probably due to the multiple attempts of the neuraxial techniques, and this diagnostic hypothesis was registered in the clinical process. Urinary catheterization was performed, and therapy with INN-mirabegron 25 mg and Furadantin 100 mg was started despite the negative urine culture.
The magnetic resonance imaging of the lower back of the spine showed no abnormality and a diagnosis of cauda equina neuritis, secondary to the use of ropivacaine, was put forward by the neurology team.
The urological examination showed that the clinical condition could be a possible complication due to the use of forceps that caused stretching of the pudendal nerve.
Before discharge, the patient's family collected the biographical data of the anesthetists responsible for the labor analgesia in order to prepare a possible legal proceeding.
The patient was discharged wearing a urinary catheter and with instruction to discontinue INN-mirabegron. There was a recovery of bladder function, and the patient was followed up with no recurrence of the clinical condition after 15 months.
Although the incidence of postpartum obstetric neuropathy is relatively common, the symptoms are generally indolent and self-limited, rarely resulting in serious permanent consequences.  The anesthesiologist must be aware of the complexity and multiplicity of mechanisms involved in postpartum neurological lesions, with urinary retention being one of its possible signs. It is also important for them to acknowledge their lack of awareness of the obstetric factors often involved in AUR and seek help from colleagues of various specialties who may be required to assess these clinical conditions.
In this case, all the major risk factors including neuraxial analgesia, instrumental labor, nulliparity, and episiotomy for developing AUR coexist.
Neuraxial analgesia may result in AUR due to the drugs used; however, this is less likely to occur 72 h after the last administration of the drug. The traumatic lesion of the spinal cord while performing neuraxial techniques is unlikely approaching level L4-L5 and has been excluded by imaging tests as well as epidural hematoma and abscess. Conus medullaris and cauda equina syndromes, despite coursing with urinary retention, are nosological entities usually associated with other changes in the neurological examnation  that have not been found in this case.
Ropivacaine is the local anesthetic drug that shows less potential neurotoxicity when administered in the subarachnoid space.  The clinical scenarios described in the literature associated with local anesthetics do not manifest themselves as isolated AUR (such as the transient neurological syndrome) and are unlikely in the case of 2 mg dose. Therefore, in this case, it is a very remote diagnostic hypothesis. ,,
Although spontaneous micturition occurred after the catheter was removed, a posturination  residual volume could have gone unnoticed until the emergence of symptomatic urinary retention, which could explain the 72-h interval to symptom presentation.
Assuming the contribution of the risk factors listed above, we would expect the urinary retention to start 6 h after removing the catheter. However, this was not observed and the patient urinated on the third day in the postpartum period.
Moreover, the use of mirabegron (a selective agonist of the beta-3 adrenergic receptors approved for the treatment of overactive bladder) was not appropriate since it is approved for the treatment of a clinical condition diametrically opposed to the present one. This may have contributed to the delaying resolution of urinary retention. 
Pudendal nerve lesion during labor instrumentation best explains the clinical condition although there are several factors involved that may have also contributed to the condition.
The findings of this study indicate that there must be a cautious attitude during the practice of medicine when allocating responsibilities, particularly in clinical syndromes not yet well-explained. It is important to bear in mind that all medical procedures have inevitable adverse effects and complications, which are not associated with malpractice errors. 
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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