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LETTER TO THE EDITOR
Year : 2012  |  Volume : 2  |  Issue : 2  |  Page : 112-113

Ipsilateral Horner's syndrome associated with epidural anaesthesia in a emergency cesarean section


Department of Anaesthesia and Intensive Care, Safdarjang Hospital, New Delhi, India

Date of Web Publication17-Dec-2012

Correspondence Address:
Gaurav Chauhan
M-4/15, Near Arya Samaj Mandir, Model Town III, New Delhi - 110 009
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.104739

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How to cite this article:
Chauhan G, Nayar P, Kashyap C. Ipsilateral Horner's syndrome associated with epidural anaesthesia in a emergency cesarean section. J Obstet Anaesth Crit Care 2012;2:112-3

How to cite this URL:
Chauhan G, Nayar P, Kashyap C. Ipsilateral Horner's syndrome associated with epidural anaesthesia in a emergency cesarean section. J Obstet Anaesth Crit Care [serial online] 2012 [cited 2020 Nov 29];2:112-3. Available from: https://www.joacc.com/text.asp?2012/2/2/112/104739

Sir,

A 25-year-old female, gravida 1 para 1, presented in active labor at 39 weeks of gestation. She was diagnosed with preeclampsia in the second trimester of pregnancy based on clinical and laboratory findings and was advised tab. Labetalol 100 mg BD. Patient was found to be noncompliant with regard to medication on subsequent antenatal visits, which revealed high blood pressure recordings in the third trimester. Patient presented in emergency in the second stage of labor with labor pains and fetal distress. Preanesthetic examination revealed blood pressure and SpO 2 of 165/110 mmHg and 95% on room air, respectively. Laboratory investigations revealed a borderline derangement in liver function tests and platelet count of 90 Χ 10 3 /dl. The anesthetic plan of performing the procedure under epidural anesthesia was made. Patient was administered O 2 (4 L/min) via ventimask and a 15 cm wedge was placed under the left hip. Premedication administered was inj. Ranitidine 50 mg I.V. and inj. Metoclopramide 10 mg I.V. A lumbar epidural catheter was placed via mid-line approach, confirmed by loss of resistance technique with the patient in sitting position and was threaded up to a length of 5 cm at the interspace between the third and fourth lumbar vertebrae. A test dose of 3 ml of 2% lidocaine with epinephrine 5 μg/ml was administered without appreciable evidence of either intravascular or intrathecal placement of the catheter. A bolus of 10 ml of 0.5% bupivacaine with fentanyl 2 μg/ml was administered over 5 min. Upper level of analgesia at the T4 segment was achieved bilaterally. Surgery went ahead and a live issue was delivered. Inj. Oxytocin I.V. (15 units/500 ml of Ringer lactate at 40 drops/min) was started slowly after delivery. Twenty minutes into surgery, the patient complained of tingling sensation on left cheek, which gradually increased to numbness. She did not complain of any dyspnea or any other neurological deficit. A careful examination revealed miosis and ptosis on the left side with level of analgesia at the fourth thoracic segment both on the left and the right. However, there were no motor deficits in the upper limb, and the grip strength on the right side was normal with a slight decrease in the left. Patient's vital parameters remained inconsequential throughout the course of 45 min long procedure except for two episodes of hypotension, which were managed with inj. Mephentermine 3 mg I.V. and augmenting the rate of I.V. fluid administration. After shifting the patient to the recovery room, epidural catheter was removed and inj. Tramadol 50 mg I.M. was advised for postoperative analgesia. Two hours after the surgical procedure the patient's symptoms of facial numbness, ptosis, and miosis gradually reversed.

Claude Bernard-Horner's syndrome or oculosympathetic palsy, first described in 1869, encompasses drooping of eyelid, constriction of the pupil, decreased sweating of the face on the same side and conjunctival congestion is often present together with loss of ciliospinal reflex. [1] Incidence of Horner's syndrome associated with labor epidural is reportedly 0.4-2.5% and is believed to be caused by cephalad spread of the local anesthetic solution disrupting the oculosympathetic pathway where second order neurons exit the spinal cord (8 th cervical and 1 st thoracic nerves) on their path to the superior cervical ganglion. [1],[2] This can be postulated due to changes in anatomy of the epidural space associated with pregnancy, unilateral catheter placement, secondary to dural puncture with subarachnoid injection of the anesthetic solution, and can be augmented by the presence of concomitant uterine contractions. [3],[4] Horner's syndrome associated with neuraxial blockade, although distressing for the patient, is reported to be self-limiting but it should sensitize the attending physician toward the hemodynamic instability associated with a high sympathetic block. [5] A high index of caution needs to be exercised during lumbar epidural anesthesia in laboring parturients regarding Horner's syndrome.

 
  References Top

1.Carrero EJ, Agustí M, Fabregas N, Valldeoriola F, Fernández C. Unilateral trigeminal and facial nerve palsies associated with epidural analgesia in labour. Can J Anaesth 1998;45:893-7.   Back to cited text no. 1
    
2.Schachner SM, Reynolds AC. Horner syndrome during lumbar epidural analgesia for obstetrics. Obstet Gynecol 1982;59(6 Suppl):31S-2.   Back to cited text no. 2
    
3.Paw HG. Horner's syndrome following low-dose epidural infusion for labour: A cautionary tale. Eur J Anaesthesiol 1998;15:110-1.   Back to cited text no. 3
[PUBMED]    
4.Wong SY, Lin CF, Lo LM, Peng TC, Chuah EC. Postpartum unilateral Horner's syndrome following lumbar epidural anesthesia after a Cesarean delivery. Chang Gung Med J 2004;27:624-8.   Back to cited text no. 4
[PUBMED]    
5.Merrison AF, Lhatoo SD. Horner's syndrome postpartum. BJOG 2004;111:86-8.  Back to cited text no. 5
[PUBMED]    



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