A case of unilateral ptosis following epidural anesthesia for cesarean section

Murali Chakravarthy; Anitha Prashant; Rohini Mayur

doi:10.4103/2249-4472.132827

CASE REPORT

Year : 2014 | Volume : 4 | Issue : 1 | Page : 48-49

A case of unilateral ptosis following epidural anesthesia for cesarean section

Murali Chakravarthy, Anitha Prashant, Rohini Mayur
Departments of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India

Date of Web Publication

20-May-2014

Correspondence Address:
Murali Chakravarthy
Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bannerughatta Road, Bengaluru - 560 076, Karnataka
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2249-4472.132827

Abstract

The present case report describes an unreported complication of self limiting unilateral ptosis after uneventful lumbar epidural analgesia followed by anaesthesia for caesarean section.

Keywords: Labor epidural analgesia, ptosis, temporary, unilateral

How to cite this article:
Chakravarthy M, Prashant A, Mayur R. A case of unilateral ptosis following epidural anesthesia for cesarean section. J Obstet Anaesth Crit Care 2014;4:48-9

How to cite this URL:
Chakravarthy M, Prashant A, Mayur R. A case of unilateral ptosis following epidural anesthesia for cesarean section. J Obstet Anaesth Crit Care [serial online] 2014 [cited 2023 Mar 27];4:48-9. Available from: https://www.joacc.com/text.asp?2014/4/1/48/132827

Introduction

Epidural analgesia is considered the standard technique to alleviate labor pain. Though time tested, epidural analgesia is not without adverse consequences, which range from transient hypotension to permanent neurologic deficit. Here, we present a case of transient unilateral ptosis following epidural analgesia/anesthesia, which resolved without further interventions.

Case report

The case we present here is about a 29-year-old, primigravida presented to our hospital with labor pain at term gestation. She had no associated comorbidities, and did not suffer from any kind of neurologic problems. She was 167 cm tall and weighed 78 kg. Obstetrician who examined her confirmed that she was in active labor and the patient requested for labor epidural analgesia. Informed written consent was obtained and an intravenous access was obtained and the patient was preloaded with 500 ml of Ringer's lactate. Under full aseptic precautions an epidural catheter was inserted in L3-L4 interspace in a sitting position. Monitoring of electrocardiogram, noninvasive blood pressure, oxygen saturation, and fetal heart rate was commenced. The epidural space was identified in the midline by loss of resistance to saline using 16G epidural needle. The epidural space was located at a depth of 5 cm. Epidural catheter was inserted without difficulty and 4 cm of the catheter was left indwelling. A test dose of 2.5 ml of 2% lignocaine with 1:200,000 adrenaline was administered. When no adverse events were noted to the test dose, a bolus of 12 ml of ropivacaine 0.1% with fentanyl 25 μg was administered through the epidural catheter. The patient had good labor pain relief without any motor block. All the hemodynamic parameters remained stable. Ninety minutes into the labor analgesia, the obstetrician noted meconium stained liquor and scheduled the patient for an immediate lower section cesarean section (LSCS). The patient was transferred to the operation theater and the monitoring provided in the labor room was now continued in the operation theater. In order to provide anesthesia for LSCS, 9 ml of 2% lignocaine with 1:200,000 adrenaline mixed with 1 ml of 7.5% sodium bicarbonate was administered through the epidural catheter. After 5 min, the level of analgesia was noted to beT6 as tested by loss of temperature sense (tested using alcohol swabs) and the obstetrician proceeded with LSCS. Prophylactic antibiotic of cefuroxime 1.5 g was administered intravenously prior to skin incision. A live healthy baby was extracted with good Apgar score at 1 min and 10 min. Oxytocin 10 units was administered intravenously as per institution protocol and rest of the procedure was uneventful. Patient was transferred to postanesthesia care unit after completion of the surgery. The epidural catheter was kept in situ and no further medications were administered through the epidural catheter.

An hour later, the patient reported paraesthesia in the right upper eye lid and inability to close her right upper eyelid. On examination, patient had ptosis on the right side and inability to close the right upper eyelid. She had no other features of sensory or motor weakness, anywhere else in the body. Examination of the cranial nerves was normal. By that time, she had already recovered from the sensory and motor block of the epidural that had been administered for carrying out LSCS. She remained hemodynamically stable and had no other complaint. The situation was discussed with the hospital neurologist about further management. We did not obtain a neurologic consult, because, in a matter of about few hours, the weakness of the eye lid started to improve and it completely resolved in 12 h. The patient made an uneventful recovery thereafter.

Discussion

Though isolated cases of temporary deficits involving the cranial nerves after lumbar epidural anesthesia have been reported ^[1] isolated ptosis is unreported to our knowledge.

Horner's syndrome has been reported following lumbar epidural analgesia in obstetrics. The reported incidence of Horner's syndrome is 0.4-2.5% in the setting of epidural for childbirth and 4% in cesarean sections. ^[2] The Horner's syndrome is typically transient, but one case of persistent Horner's syndrome has been reported ^[3] with an average onset of 25 min after administering the epidural block, and a mean duration of 215 min until spontaneous resolution. ^[4]

There are several possible reasons for the occurrence of Horner's syndrome after lumbar epidural anesthesia in obstetrics. The preganglionic fibers supplying the eyelid may arise as low as fourth thoracic dermatome. Decreased volume of the epidural space due to engorged epidural veins (which occurs commonly in pregnancy) may result in increased cephalic spread of the epidural drug affecting these fibers. In addition, injection of local anesthetic medication during the uterine contraction may result in further cephalad migration of the drug. Other contributory factors include patient positioning and a greater sensitivity of sympathetic preganglionic B fibers to the action of local anesthetic agents. ^[5] In some cases, Horner's syndrome was attributed to inadvertent partial dural puncture and subarachnoid injection of the local anesthetic solution. ^[1] Horner's syndrome complicating epidural anesthesia usually occurs unilaterally, which may be due to asymmetrical positioning of the catheter in the extradural space, or anatomical changes in the extradural space of pregnant women. ^[1],[6]

Eyelid receives its innervations from three cranial nerves (oculomotor, trigeminal, facial) and sympathetic fibers. Ptosis can occur because of lesions at the supranuclear level, oculomotor complex, oculosympathetic system, and myopathy or lid abnormality. Our patient had received a neuraxial block in the preceding few hours, therefore it is but logical to suspect sympathetic nerve block due to the local anesthetic used. Such involvement could have resulted in Horner's syndrome under usual circumstances; but in the present case, other manifestations of Horner's syndrome such as miosis, anhidrosis, and ipsilateral facial flushing were absent and the ptosis was significant, while in classical Horner's syndrome it is very mild. It is difficult to explain the occurrence of isolated ptosis in our case. Suspicion of myopathies, including ocular myasthenia as the etiology, were not encouraged, because the patient had not received general anesthesia and neuromuscular blocking agents had not been used.

Conclusion

A case of self-resolving unilateral ptosis is reported after administering labor epidural analgesia followed by anaesthesia.

References

1.	Narouze SN, Basali A, Mandel M, Tetzlaff JE. Horner's syndrome and trigeminal nerve palsy after lumbar epidural analgesia for labor and delivery. J Clin Anesth 2002;14:532-4.
2.	Clayton KC. The incidence of Horner's syndrome during lumbar extradural for elective Caesarean section and provision of analgesia during labour. Anaesthesia 1983;38:583-5. [PUBMED]
3.	Goel S, Burkat CN. Unusual case of persistent Horner's syndrome following epidural anaesthesia and caesarean section. Indian J Ophthalmol 2011;59:389-91. [PUBMED]
4.	Lynch JH, Keneally RJ, Hustead TR. Horner's syndrome and trigeminal nerve palsy following epidural analgesia for labor. J Am Board Fam Med 2006;19:521-3.
5.	Biousse V, Guevara RA, Newman NJ. Transient Horner's syndrome after lumbar epidural anesthesia. Neurology 1998;51:1473-5.
6.	Sprung J, Haddox JD, Maitra-D'Cruze AM. Horner's syndrome and trigeminal nerve palsy following epidural anaesthesia for obstetrics. Can J Anaesth 1991;38:767-71.