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Moita Gonçalves E, Lanzaro C, Silva LC, Correia P, Gonçalves JV, Azevedo M, Carrapatoso I, Silva JP, Carvalho C, Cruz A. Enhancing functional recovery following postpartum femoral neuropathy: early neurorehabilitation and multidisciplinary obstetric care. Int J Gynaecol Obstet 2024; 164:830-834. [PMID: 37537869 DOI: 10.1002/ijgo.15025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/26/2023] [Accepted: 07/11/2023] [Indexed: 08/05/2023]
Abstract
Postpartum femoral neuropathy has a reported incidence of less than 1% and its total recovery time extends up to 6 months to a year. A multidisciplinary approach is vital to rule out permanent disability and to assure a correct diagnosis and earlier rehabilitation. We report a case of a 37-year-old puerperal woman with a history of intrapartum epidural analgesia, who presented post-labor unilateral lower-limb motor weakness and sensory loss, with functional compromise on independent gait. A multidisciplinary team consisting of an anesthesiologist, a physiatrist, a neurologist, and an obstetrician was then established. In the initial physiatry and neurology assessment, the patient reported pain (numerical rating scale 7/10) over the inguinal ligament, lower limb hypoesthesia, and muscle weakness. Femoral neuropathy was suspected. Magnetic resonance imaging ruled out potential complications related to the anesthetic procedure. The patient was then enrolled in a supervised rehabilitation program and, 3 weeks later, electrodiagnostic studies confirmed the initial suspicion. Two months later, the patient had regained lower-limb active range of motion and no pain nor paresthesia was reported. Our case report describes how an early multimodal rehabilitation program within a multidisciplinary framework allows for sooner neuromotor function improvement and activities of daily living independence.
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Affiliation(s)
- Eugénio Moita Gonçalves
- Physical Medicine and Rehabilitation Department, Centro Hospitalar Vila Nova de Gaia-Espinho, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
- Egas Moniz Health Alliance Clinical Academic Center, Aveiro, Portugal
| | - Camile Lanzaro
- Anesthesiology Department, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
| | - Luísa Cunha Silva
- Gynecology and Obstetrics Department, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
| | - Pedro Correia
- Neurology Department, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
| | - José Vítor Gonçalves
- Physical Medicine and Rehabilitation Department, Centro Hospitalar Vila Nova de Gaia-Espinho, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Marta Azevedo
- Physical Medicine and Rehabilitation Department, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
| | - Inês Carrapatoso
- Anesthesiology Department, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
| | - João Pedro Silva
- Gynecology and Obstetrics Department, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
| | - Carolina Carvalho
- Physical Medicine and Rehabilitation Department, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
| | - André Cruz
- Physical Medicine and Rehabilitation Department, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal
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Li J, Chongpison Y, Amornvit J, Chaikittisilpa S, Santibenchakul S, Jaisamrarn U. Association of reproductive factors and exogenous hormone use with distal sensory polyneuropathy among postmenopausal women in the United States: results from 1999 to 2004 NHANES. Sci Rep 2023; 13:9274. [PMID: 37286578 DOI: 10.1038/s41598-023-35934-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 05/25/2023] [Indexed: 06/09/2023] Open
Abstract
Postmenopausal status is a risk factor for distal sensory polyneuropathy-the most common type of peripheral neuropathy. We aimed to investigate associations between reproductive factors and history of exogenous hormone use with distal sensory polyneuropathy among postmenopausal women in the United States using data from the National Health and Nutrition Examination Survey 1999-2004, and to explore the modifying effects of ethnicity on these associations. We conducted a cross-sectional study among postmenopausal women aged ≥ 40 years. Women with a history of diabetes, stroke, cancer, cardiovascular disease, thyroid disease, liver disease, weak or failing kidneys, or amputation were excluded. Distal sensory polyneuropathy was measured using a 10-g monofilament test, and a questionnaire was used to collect data on reproductive history. Multivariable survey logistic regression was used to test the association between reproductive history variables and distal sensory polyneuropathy. In total, 1144 postmenopausal women aged ≥ 40 years were included. The adjusted odds ratios were 8.13 [95% confidence interval (CI) 1.24-53.28] and 3.18 (95% CI 1.32-7.68) for age at menarche < 11 years and time since menopause > 20 years, respectively, which were positively associated with distal sensory polyneuropathy; adjusted odds ratios were 0.45 for the history of breastfeeding (95% CI 0.21-0.99) and 0.41 for exogenous hormone use (95% CI 0.19-0.87) were negatively associated. Subgroup analysis revealed ethnicity-based heterogeneity in these associations. Age at menarche, time since menopause, breastfeeding, and exogenous hormone use were associated with distal sensory polyneuropathy. Ethnicity significantly modified these associations.
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Affiliation(s)
- Jiayu Li
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yuda Chongpison
- Center of Excellence in Biostatistics, Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
- The Skin and Allergy Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Jakkrit Amornvit
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sukanya Chaikittisilpa
- Menopause Research Group, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somsook Santibenchakul
- Family Planning and Reproductive Health Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Rama 4 Road, Bangkok, 10330, Thailand.
| | - Unnop Jaisamrarn
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Trager RJ, Prosak SE, Getty PJ, Barger RL, Saab ST, Dusek JA. Ischial osteochondroma as an unusual source of pregnancy-related sciatic pain: a case report. Chiropr Man Therap 2022; 30:45. [PMID: 36253863 PMCID: PMC9575271 DOI: 10.1186/s12998-022-00451-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/23/2022] [Accepted: 09/07/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND While most cases of sciatica result from degenerative conditions of the low back, some cases result from conditions of the hip and pelvic region. Sciatica developing in relation to pregnancy or labor also presents unique considerations. CASE PRESENTATION A 37-year-old African American woman with a history of hypertension and polycystic ovary syndrome presented to a chiropractor at a hospital-based outpatient clinic with a seven-week history of low back pain with radiation into the right lower extremity which began during labor. The chiropractor performed a brief trial of care, yet when the patient's symptoms worsened, ordered lumbar spine radiographs, followed by lumbar magnetic resonance imaging (MRI), which were both normal. The chiropractor then ordered hip radiographs, which were suggestive of ischial osteochondroma, and referred the patient to an orthopedic oncologist. MRI findings were compatible with an osteochondroma with associated adventitial bursitis and mass effect on the sciatic nerve. The patient initially chose conservative management with bursa aspiration and therapeutic injection. Despite initial relief, there was eventual return of symptoms. The patient elected to undergo surgical removal, with a positive outcome. CONCLUSION The key distinguishing features that led to a diagnosis of osteochondroma in this case included attention to the patient-reported symptoms and history, worsening of symptoms despite conservative care, and lack of explanatory findings on lumbar imaging. This case highlights the benefit of evaluating the hip and pelvis when the clinical features of sciatica cannot be ascribed to a lumbar etiology. This case also illustrates the role of a chiropractor working in an integrative health system to facilitate timely imaging and referrals to resolve a challenging diagnosis.
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Affiliation(s)
- Robert J. Trager
- grid.443867.a0000 0000 9149 4843Connor Whole Health, University Hospitals Cleveland Medical Center, 44106 Cleveland, OH USA
| | - Sarah E. Prosak
- grid.443867.a0000 0000 9149 4843Connor Whole Health, University Hospitals Cleveland Medical Center, 44106 Cleveland, OH USA
| | - Patrick J. Getty
- grid.443867.a0000 0000 9149 4843Musculoskeletal Surgical Oncology, University Hospitals Cleveland Medical Center, 44106 Cleveland, OH USA ,grid.67105.350000 0001 2164 3847Orthopaedic Surgery, Case Western Reserve University, 44106 Cleveland, OH USA
| | - Richard L. Barger
- grid.443867.a0000 0000 9149 4843Division of Musculoskeletal Radiology, University Hospitals Cleveland Medical Center, 44106 Cleveland, OH USA
| | - Shahrazad T. Saab
- grid.67105.350000 0001 2164 3847Department of Pathology, Case Western Reserve University School of Medicine, 44106 Cleveland, OH USA
| | - Jeffery A. Dusek
- grid.443867.a0000 0000 9149 4843Connor Whole Health, University Hospitals Cleveland Medical Center, 44106 Cleveland, OH USA ,grid.67105.350000 0001 2164 3847Department of Family Medicine and Community Health, School of Medicine, Case Western Reserve University, 44106 Cleveland, OH USA
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Matičič UB, Šumak R, Omejec G, Salapura V, Snoj Ž. Ultrasound-guided injections in pelvic entrapment neuropathies. J Ultrason 2021; 21:e139-e146. [PMID: 34258039 PMCID: PMC8264816 DOI: 10.15557/jou.2021.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/09/2021] [Indexed: 11/22/2022] Open
Abstract
Pelvic entrapment neuropathies represent a group of chronic pain syndromes that significantly impede the quality of life. Peripheral nerve entrapment occurs at specific anatomic locations. There are several causes of pelvic entrapment neuropathies, such as intrinsic nerve abnormality or inflammation with scarring of surrounding tissues, and surgical interventions in the abdomen, pelvis and the lower limbs. Entrapment neuropathies in the pelvic region are not widely recognized, and still tend to be underdiagnosed due to numerous differential diagnoses with overlapping symptoms. However, it is important that entrapment neuropathies are correctly diagnosed, as they can be successfully treated. The lateral femoral cutaneous nerve, ischiadic nerve, genitofemoral nerve, pudendal nerve, ilioinguinal nerve and obturator nerve are the nerves most frequently causing entrapment neuropathies in the pelvic region. Understanding the anatomy as well as nerve motor and sensory functions is essential in recognizing and locating nerve entrapment. The cornerstone of the diagnostic work-up is careful physical examination. Different imaging modalities play an important role in the diagnostic process. Ultrasound is a key modality in the diagnostic work-up of pelvic entraptment neuropathies, and its use has become increasingly widespread in therapeutic procedures. In the article, the authors describe the background of pelvic entrapment neuropathies with special focus on ultrasound-guided injections.
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Affiliation(s)
- Urša Burica Matičič
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, Ljubljana, Slovenia
| | - Rok Šumak
- Department of General Gynaecology and Urogynaecology, Clinic for Gynaecology and Perinatology, University Medical Centre Maribor, Maribor, Slovenia
| | - Gregor Omejec
- Institute of Clinical Neurophysiology, Division of Neurology, University Medical Center Ljubljana, Zaloška 7, Ljubljana, Slovenia
| | - Vladka Salapura
- Radiology Institute, University Medical Centre Ljubljana, Zaloška 7, Ljubljana, Slovenia
| | - Žiga Snoj
- Radiology Institute, University Medical Centre Ljubljana, Zaloška 7, Ljubljana, Slovenia
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Choo HJ, Hwang SK, Hynes CK. Musculoskeletal Issues and Care for Pregnant and Postpartum Women. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00286-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Many neuromuscular disorders preexist or occur during pregnancy. In some cases, pregnancy unmasks a latent hereditary disorder. Most available information is based on case reports or series or retrospective clinical experience or patient surveys. Of special interest are pregnancy-induced changes in disease course or severity and likelihood for baseline recovery of function postpartum. Labor and delivery present special challenges in many conditions that affect skeletal but not smooth (uterine) muscle; so labor complications must be anticipated. Anesthesia for cesarean section surgery requires special precautions in many disorders. The types of conditions reviewed are broad and include examples of autoimmune, hereditary, and compressive/mechanical processes. Disorders include carpal tunnel syndrome and other focal neuropathies, Bell palsy, myasthenia gravis, and other neuromuscular junction disorders, acute and chronic inflammatory neuropathy, hereditary and acquired muscle diseases, spinal muscular atrophy, amyotrophic lateral sclerosis, channelopathies, autonomic neuropathy, and dysautonomia. Many commonly used therapies have fetal animal but no proven human toxicity concerns, complicating treatment and risk decisions. Weaning off effective therapeutic agents or preemptive aggressive treatment or surgery prior to planned pregnancy is an option in some conditions.
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Affiliation(s)
- Louis H. Weimer
- Correspondence to: Louis H. Weimer, M.D., Neurological Institute of New York, 710 W. 168th Street, New York, NY 10032, United States. Tel: + 1-212-305-1516, Fax: + 1-212-305-4268
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Abstract
A 34-year-old primiparous woman presented in spontaneous labour and had an unassisted vaginal birth of a 3.5 kg infant. Postnatally, the patient experienced lower limb weakness and was unable to mobilise unassisted. A diagnosis of postpartum femoral neuropathy was made. Full recovery of normal motor function was not achieved until 5 months postpartum. She returned in her next pregnancy, seeking advice on how to avoid this complication from reoccurring. It was decided that an elective caesarean section was an appropriate mode of delivery, which she underwent at 39 weeks without complication and without recurrence of the femoral neuropathy.
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Affiliation(s)
- Cathy Rowland
- Obstetrics & Gynaecology, Rotunda Hospital, Dublin, Ireland
| | - Daniel Kane
- Obstetrics & Gynaecology, Rotunda Hospital, Dublin, Ireland
| | - Maeve Eogan
- Obstetrics & Gynaecology, Rotunda Hospital, Dublin, Ireland
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Hakeem R, Neppe C. Intrinsic Obstetric Palsy: Case Report and Literature Review. J Clin Diagn Res 2016; 10:QD06-7. [PMID: 27190901 DOI: 10.7860/jcdr/2016/18797.7693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 03/23/2016] [Indexed: 11/24/2022]
Abstract
Maternal neurological injuries may be intrinsic to the labour and delivery process or may result directly or indirectly from obstetric or anaesthetic intervention. This intrinsic obstetric palsy is a rare complication of labour but can have devastating impact on a previously healthy mother. A 23-year-old gravida1, para0 who had epidural for labour analgesia, was augmented for slow progress and had a normal vaginal delivery. She was diagnosed post delivery with intrinsic obstetric palsy involving several peripheral nerves and lumbosacral nerve roots with a guarded prognosis. In this article we have discussed the risk factors and mechanisms of intrinsic obstetric palsy and proposed further investigation into the potential protective role of ambulatory analgesia i.e. CSE (Combined Spinal Epidural) or LDI (Low Dose Infusion).
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Affiliation(s)
- Rashida Hakeem
- CMO, Department of Obstetrics & Gynaecology, Joondalup Health Campus , Joondalup WA Australia
| | - Cliff Neppe
- Director, Department of Obstetrics & Gynaecology, Joondalup Health Campus , Joondalup WA Australia
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Kamphuis VP, Zegers MP, Koppen H. Bilateral Heel Numbness due to External Compression during Obstetric Epidural Analgesia. Case Rep Neurol 2015; 7:15-7. [PMID: 25802500 PMCID: PMC4357682 DOI: 10.1159/000375233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We describe the case of a 32-year-old woman who developed bilateral heel numbness after obstetric epidural analgesia. We diagnosed her with bilateral neuropathy of the medial calcaneal nerve, most likely due to longstanding pressure on both heels. Risk factors for the development of this neuropathy were prolonged labour with spinal analgesia and a continuation of analgesia during episiotomy. Padded footrests decrease pressure and can possibly prevent this neuropathy.
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Affiliation(s)
- Vivian P. Kamphuis
- Department of Neurology, Hagaziekenhuis, The Hague, The Netherlands
- Department of Leiden University Medical Center, Leiden, The Netherlands
| | - Marie P.A. Zegers
- Department of Obstetrics and Gynecology, Hagaziekenhuis, The Hague, The Netherlands
| | - Hille Koppen
- Department of Neurology, Hagaziekenhuis, The Hague, The Netherlands
- *Hille Koppen, MD, Hagaziekenhuis, PO Box 40551, NL-2504 LN The Hague (The Netherlands), E-Mail
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10
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An Uncommon Case of Bilateral Peroneal Nerve Palsy following Delivery: A Case Report and Review of the Literature. Case Rep Obstet Gynecol 2014; 2014:746480. [PMID: 25180116 PMCID: PMC4142536 DOI: 10.1155/2014/746480] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 07/22/2014] [Indexed: 11/17/2022] Open
Abstract
Peroneal nerve palsy is an infrequent but potential complication of childbirth. Bilateral peroneal palsy is particularly rare following delivery with few reported cases. A 38-year-old gravida 1, para 0 underwent a prolonged second stage of labor, was diagnosed with an arrest of descent, and subsequently underwent an uncomplicated primary cesarean section. The patient was diagnosed with bilateral peroneal neuropathy four days after delivery. By two months postpartum, her foot drop had improved by 85% and the remainder of her symptoms resolved. Awareness of the risks of a peroneal neuropathy as well as implementation of preventive measures is important for members of the delivery team. Regional anesthesia during labor is a risk factor for the development of a peroneal neuropathy.
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Nieuwenhuijze MJ, Low LK, Korstjens I, Lagro-Janssen T. The role of maternity care providers in promoting shared decision making regarding birthing positions during the second stage of labor. J Midwifery Womens Health 2014; 59:277-85. [PMID: 24800933 PMCID: PMC4064714 DOI: 10.1111/jmwh.12187] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Through the use of a variety of birthing positions during the second stage of labor, a woman can increase progress, improve outcomes, and have a positive birth experience. The role that a maternity care provider has in determining which position a woman uses during the second stage of labor has not been thoroughly explored. The purpose of this qualitative investigation was to explore how maternity care providers communicate with women during the second stage of labor regarding birthing position. METHODS A literature-informed framework was developed to conduct a process of deductive content analysis of communication patterns between nulliparous women and their maternity care providers during the second stage of labor. Literature discussing shared decision making, control, and predictors of positive birth experiences were reviewed to develop a coding framework. The framework included the following categories: listening to women, encouragement, information, offering choices, and style of support. Forty-one audiotapes of women and their maternity care providers during the second stage of labor were transcribed verbatim and analyzed. RESULTS Themes identified in the transcripts included all those in the analytic framework, plus 2 added categories of communication: empathy and interaction. Maternity care providers in this study enabled women to select various birthing positions using a dynamic process that moved between open, informative approaches and more closed, directive approaches, depending on the woman's needs and clinical condition. As clinical conditions unfolded, women became more actively involved in shared decision making regarding birthing positions, and maternity care providers found the right balance between being responsive to the woman's questions or directives. DISCUSSION Enabling shared decision making during birth is not a linear process using a single approach; it is dynamic process that requires a variety of approaches. Maternity care providers can support a woman to use different birthing positions during the second stage of labor by employing a flexible style that incorporates clinical assessment and the woman's responses.
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12
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Abstract
Pregnancy creates alterations in maternal physiology which predispose to unique neurologic disorders. Pre-eclampsia, eclampsia, certain types of ischemic and hemorrhagic stroke, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and thunderclap headache all appear to share a common origin from vascular endothelial dysfunction, with overlapping clinical presentations. Multiple sclerosis often improves during pregnancy. Compression mononeuropathies may occur in the extremities. Myasthenia gravis may affect second stage labor. Various inflammatory peripheral neuropathies, dystrophies, myopathies may occur during pregnancy. The safety of specific immune suppressants is reviewed. Epilepsy does not have a significant effect upon the course of pregnancy, albeit there is a modest increase in the need for cesarean section. Certain antiepileptic drugs may produce fetal malformations, most notably valproic acid. Brain tumors are rare during pregnancy, but may increase in size due to activation of hormonal receptors on tumor cells surfaces, water retention, and engorged blood vessels.
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Affiliation(s)
- H Steven Block
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - José Biller
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA.
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Ozaras N, Ergin O, Eroglu Demir S, Sariyildiz MA. Brachial plexus injury complicating the labor: mother is the victim at this time. J Matern Fetal Neonatal Med 2013; 27:1382-4. [PMID: 24147729 DOI: 10.3109/14767058.2013.858240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Postpartum nerve injuries are rare complications of labor and the lower extremity peripheral nerves are the frequently affected ones. In this case report, we are presenting a patient who developed brachial plexus injury after a forceful vaginal delivery. CASE REPORT The patient is a 28-year-old woman with right upper extremity pain, numbness and weakness, whose symptoms started just after labor. According to the clinical evaluation, electrodiagnostic study and magnetic resonance imaging, it was diagnosed as the brachial plexus injury. CONCLUSION We concluded that similar to the ones seen after some surgeries, brachial plexus may be injured also during delivery and the labor positions should be considered.
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Affiliation(s)
- Nihal Ozaras
- Physical Medicine and Rehabilitation Department, Bezmialem Vakif University , İstanbul , Turkey
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14
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Cui R, Xu S, Wang L, Lei H, Cai Q, Zhang H, Wang D. Extracts from rabbit skin inflamed by the vaccinia virus attenuate bupivacaine-induced spinal neurotoxicity in pregnant rats. Neural Regen Res 2013; 8:983-90. [PMID: 25206391 PMCID: PMC4145880 DOI: 10.3969/j.issn.1673-5374.2013.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 02/09/2013] [Indexed: 11/18/2022] Open
Abstract
Extracts from rabbit skin inflamed by the vaccinia virus can relieve pain and promote repair of nerve injury. The present study intraperitoneally injected extracts from rabbit skin inflamed by the vaccinia virus for 3 and 4 days prior to and following intrathecal injection of bupivacaine into pregnant rats. The pain threshold test after bupivacaine injection showed that the maximum possible effect of tail-flick latency peaked 1 day after intrathecal injection of bupivacaine in the extract-pretreatment group, and gradually decreased, while the maximum possible effect in the bupivacaine group continued to increase after intrathecal injection of bupivacaine. Histological observation showed that after 4 days of intrathecal injection of bupivacaine, the number of shrunken, vacuolated, apoptotic and caspase-9-positive cells in the dorsal root ganglion in the extract-pretreatment group was significantly reduced compared with the bupivacaine group. These findings indicate that extracts from rabbit skin inflamed by the vaccinia virus can attenuate neurotoxicity induced by intrathecal injection of bupivacaine in pregnant rats, possibly by inhibiting caspase-9 protein expression and suppressing nerve cell apoptosis.
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Affiliation(s)
- Rui Cui
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou 510280, Guangdong Province, China ; Department of Anesthesiology, Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen 518028, Guangdong Province, China
| | - Shiyuan Xu
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou 510280, Guangdong Province, China
| | - Liang Wang
- Department of Anesthesiology, Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen 518028, Guangdong Province, China
| | - Hongyi Lei
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou 510280, Guangdong Province, China
| | - Qingxiang Cai
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou 510280, Guangdong Province, China
| | - Hongfei Zhang
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou 510280, Guangdong Province, China
| | - Dongmei Wang
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou 510280, Guangdong Province, China
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Toledo P, Sun J, Peralta F, Grobman W, Wong C, Hasnain-Wynia R. A qualitative analysis of parturients’ perspectives on neuraxial labor analgesia. Int J Obstet Anesth 2013; 22:119-23. [DOI: 10.1016/j.ijoa.2012.11.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 11/13/2012] [Accepted: 11/24/2012] [Indexed: 10/27/2022]
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16
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Park S, Park SW, Kim KS. Lumbosacral plexus injury following vaginal delivery with epidural analgesia -A case report-. Korean J Anesthesiol 2013; 64:175-9. [PMID: 23459069 PMCID: PMC3581790 DOI: 10.4097/kjae.2013.64.2.175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 04/23/2012] [Accepted: 04/26/2012] [Indexed: 12/30/2022] Open
Abstract
A 26 year old, healthy, 41 week primiparous woman received a patient-controlled epidural analgesia (PCEA) and experienced paraplegia 11 hours later after a vaginal delivery. This was thought to be the result of complications from PCEA but there was no specific abnormality on magnetic resonance imaging (MRI) of the lumbosacral spine. On an electromyography (EMG) study performed 15 days following delivery, signs of tibial neuropathy were present and peripheral nerve injury during vaginal delivery was suspected. Motor weakness and hypoesthesia of both lower extremities improved rapidly, but a decrease in the desire to urinate or defecate, followed by urinary incontinence and constipation persisted, We suspected the sacral plexus had been severely damaged during vaginal delivery. Seven months later, the patient's conditions improved but had not fully recovered.
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Affiliation(s)
- Seil Park
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
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17
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Abstract
Peripheral nerve entrapments are frequent. They usually appear in anatomical tunnels such as the carpal tunnel. Nerve compressions may be due to external pressure such as the fibular nerve at the fibular head. Malignant or benign tumors may also damage the nerve. For each nerve from the upper and lower limbs, detailed clinical, electrophysiological, imaging, and therapeutic aspects are described. In the upper limbs, carpal tunnel syndrome and ulnar neuropathy at the elbow are the most frequent manifestations; the radial nerve is less frequently involved. Other nerves may occasionally be damaged and these are described also. In the lower limbs, the fibular nerve is most frequently involved, usually at the fibular head by external compression. Other nerves may also be involved and are therefore described. The clinical and electrophysiological examination are very important for the diagnosis, but imaging is also of great use. Treatments available for each nerve disease are discussed.
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Affiliation(s)
- P Bouche
- Department of Clinical Neurophysiology Salpêtrière Hospital, Paris, France.
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18
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Butchart AG, Mathews M, Surendran A. Complex regional pain syndrome following protracted labour*. Anaesthesia 2012; 67:1272-4. [DOI: 10.1111/j.1365-2044.2012.07301.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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20
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Kowe O, Waters JH. Neurologic Complications in the Patient Receiving Obstetric Anesthesia. Neurol Clin 2012; 30:823-33. [DOI: 10.1016/j.ncl.2012.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Vercauteren M, Waets P, Pitkänen M, Förster J. Neuraxial techniques in patients with pre-existing back impairment or prior spine interventions: a topical review with special reference to obstetrics. Acta Anaesthesiol Scand 2011; 55:910-7. [PMID: 21574965 DOI: 10.1111/j.1399-6576.2011.02443.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Many anaesthetists consider neurological disorders of all kinds as a contraindication for regional anaesthesia particularly for neuraxial techniques. This hesitation is partly rooted in fears of medicolegal problems but also in the heterogeneous literature. Therefore, the present topical review is an attempt to describe the feasibility and the risks of neuraxial techniques in patients with spinal injury, anatomical compromise, chronic back pain or previous spinal interventions, ranging from 'minor' types like epidural blood patches to major surgery such as Harrington fusions. Most reviews and case reports were describing experiences in obstetrics as these patients are more likely to insist on neuraxial blocks. In the acute phase of new neurologic injury, general anaesthesia may be the technique of choice to prevent further haemodynamic and respiratory deterioration. After the acute phase, current evidence is mostly reassuring with respect to the risks of neuraxial blocks as they may even be recommendable in some conditions. Ultrasound technology may be of additional help to increase the success rate. A careful pre-operative examination remains mandatory, while patients should be sufficiently informed about technical aspects and possible relapses or progression of their disease. When necessary, patients should have additional technical and clinical examinations as close as possible to surgery to establish the actual pre-operative status. Most patients may benefit more from spinal techniques rather than from less reliable epidural ones. High concentrations and volumes of local anaesthetics should be avoided at all times, especially in patients with nerve compression, large disc herniation or spinal stenosis.
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Affiliation(s)
- M Vercauteren
- Department of Anaesthesia, Antwerp University Hospital, Edegem, Belgium.
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22
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A manual therapy and exercise approach to meralgia paresthetica in pregnancy: a case report. J Chiropr Med 2011; 5:92-6. [PMID: 19674679 DOI: 10.1016/s0899-3467(07)60140-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Revised: 08/25/2006] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To present a case of a pregnant patient with meralgia paresthetica who improved using manual therapy and exercise procedures. CLINICAL FEATURES A 22-year-old patient in the sixteenth week of pregnancy had low back pain, bilateral anterolateral thigh paresthesia and groin pain for a duration of 1 month. She had no motor deficits in either lower extremity and her reflexes were intact. As a standard clinic procedure, a battery of functional tests were performed including: active straight leg raise, long dorsal ligament test, and the pelvic pain provocation procedure. Based on her clinical history and physical responses to the aforementioned functional tests, the diagnosis of meralgia paresthetica was deduced. INTERVENTION AND OUTCOME Treatment was provided at 6 visits over a 6-week period where the patient underwent evaluation, manual intervention, and exercise prescription. Active Release Technique (ART) was performed to the restricted right sacroiliac (SIJ) complex and quadratus lumborum muscles. ART and post-isometric relaxation were applied to the illiopsoas muscles. The home exercise program consisted of pelvic/low back mobility, stabilization and relaxation exercises. After 6 treatments, the patient reported complete resolution of low back pain and left lower extremity symptoms and a 90% improvement in the right thigh symptoms. At her one-year follow-up, the patient reported no further complications and the absence of pain. CONCLUSIONS Manual therapy and exercises may serve as an effective treatment protocol for pregnant patients experiencing low back pain complicated by paresthesia. Because these conservative procedures offer a low-risk intervention, additional clinical studies are warranted to further study this treatment.
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Chung KH, Lee JY, Ko TK, Park CH, Chun DH, Yang HJ, Gill HJ, Kim MK. Meralgia paresthetica affecting parturient women who underwent cesarean section -A case report-. Korean J Anesthesiol 2010; 59 Suppl:S86-9. [PMID: 21286469 PMCID: PMC3030065 DOI: 10.4097/kjae.2010.59.s.s86] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 05/18/2010] [Accepted: 06/23/2010] [Indexed: 11/15/2022] Open
Abstract
Meralgia paresthetica is commonly caused by a focal entrapment of lateral femoral cuteneous nerve while it passes the inguinal ligament. Common symptoms are paresthesias and numbness of the upper lateral thigh area. Pregnancy, tight cloths, obesity, position of surgery and the tumor in the retroperitoneal space could be causes of meralgia paresthetica. A 29-year-old female patient underwent an emergency cesarean section under spinal anesthesia without any problems. But two days after surgery, the patient complained numbness and paresthesia in anterolateral thigh area. Various neurological examinations and L-spine MRI images were all normal, but the symptoms persisted for a few days. Then, electromyogram and nerve conduction velocity test of the trunk and both legs were performed. Test results showed left lateral cutaneous nerve injury and meralgia paresthetica was diagnosed. Conservative treatment was implemented and the patient was free of symptoms after 1 month follow-up.
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Affiliation(s)
- Kum Hee Chung
- Department of Anesthesiology and Pain Medicine, CHA University School of Medicine, Seongnam, Korea
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Abstract
Epidural analgesia is an extremely effective and popular treatment for labor pain. In this review, we trace the history of the use of epidural analgesia and its refinements. We then outline the goals of treatment and methods used to attain those goals. The use of low concentrations of local anesthetics, combined with lipid-soluble opioids, does not impede the progress of labor or depress the newborn. The incidence of side effects is low. Maintenance of analgesia that allows patient control enhances patient satisfaction.
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Affiliation(s)
- Marcos Silva
- Department of Anesthesia, Sunnybrook Health Sciences Centre
and University of Toronto, Toronto, Canada
| | - Stephen H Halpern
- Department of Anesthesia, Sunnybrook Health Sciences Centre
and University of Toronto, Toronto, Canada
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25
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Hayes N, Wheelahan J, Ross A. Self-reported post-discharge symptoms following obstetric neuraxial blockade. Int J Obstet Anesth 2010; 19:405-9. [DOI: 10.1016/j.ijoa.2010.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2008] [Revised: 12/31/2009] [Accepted: 04/09/2010] [Indexed: 10/19/2022]
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26
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Nerve injuries after neuraxial anaesthesia and their medicolegal implications. Best Pract Res Clin Obstet Gynaecol 2010; 24:367-81. [PMID: 20053587 DOI: 10.1016/j.bpobgyn.2009.11.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Accepted: 11/25/2009] [Indexed: 11/21/2022]
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27
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Paech M, Sinha A. Obstetric audit and its implications for obstetric anaesthesia. Best Pract Res Clin Obstet Gynaecol 2010; 24:413-25. [DOI: 10.1016/j.bpobgyn.2009.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Accepted: 12/01/2009] [Indexed: 10/20/2022]
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28
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Síndrome de compresión del plexo lumbosacro durante el embarazo. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2009. [DOI: 10.1016/j.gine.2008.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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29
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Díaz Allegue M, González Bardanca S, Pato López O, Abeledo Fernández MA, Rama Maceiras P. [Epidural anesthesia in labor and conversion disorder]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2009; 56:312-4. [PMID: 19580134 DOI: 10.1016/s0034-9356(09)70400-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 37-year-old woman came to our hospital at the beginning of labor. She reported a history of depression with attempted suicide some years earlier and had also undergone dilation and curettage following an abortion; on admission to our hospital, she was euthymic and not receiving treatment. The patient requested epidural analgesia. Several hours later, she reported dorsal foot numbness and difficulty performing dorsal flexion. After an organic cause had been ruled out, a diagnosis of conversion disorder was considered. The incidence of this psychiatric disorder is high, though it is usually underdiagnosed. Conversion disorder involves at least 1 neurologic symptom suggestive of organic disease. Symptoms are not feigned and cannot be ascribed to a medical disease, the effects of a toxic substance, or culturally normal behavior, yet there is significant clinical, social, and occupational deterioration.
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Affiliation(s)
- M Díaz Allegue
- Servicio de Anestesiología y Reanimación, Hospital Universitario Juan Canalejo, A Coruña.
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30
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Domínguez Suárez E, Pardo-Sobrino F, Pensado Castiñeiras A, Cores Viqueira MJ, López-Rouco M. [Obturator nerve lesion after a vaginal delivery without instrumentation under epidural analgesia]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2009; 56:195-196. [PMID: 19408791 DOI: 10.1016/s0034-9356(09)70367-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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31
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Birnbach DJ, Ranasinghe JS. Anesthesia complications in the birthplace: is the neuraxial block always to blame? Clin Perinatol 2008; 35:35-52, vii. [PMID: 18280874 DOI: 10.1016/j.clp.2007.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This article highlights the common and some of the very serious complications that may occur following neuraxial analgesia for labor and delivery, including headache, backache, infection, hypotension, and hematoma. Total spinal and failed block also are discussed, as are complications unique to epidural anesthesia, such as the intravascular injection of large volumes of local anesthetic (causing seizure or cardiac arrest) and accidental dural puncture.
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Affiliation(s)
- David J Birnbach
- Department of Anesthesiology, University of Miami-Jackson Memorial Hospital Center for Patient Safety, Miller School of Medicine, University of Miami, Miami, FL 33136, USA.
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Ley L, Ikhouane M, Staiti G, Benhamou D. Complication neurologique après posture obstétricale «en tailleur» lors d'un travail sous analgésie péridurale. ACTA ACUST UNITED AC 2007; 36:496-9. [PMID: 17482772 DOI: 10.1016/j.jgyn.2007.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Revised: 10/04/2006] [Accepted: 03/20/2007] [Indexed: 11/21/2022]
Abstract
Obstetrical positioning is used more and more often because of the supposed or proven benefits although side effects are not well known. We therefore report the case of a patient who presented with a postpartum neurological deficit after a seven hour hip-flexed posture during labour under epidural analgesia. The parturient did not complain of pain or discomfort during labour. The neurological injury was suspected because of delayed recovery of epidural analgesia induced-motor block. Neurological examination disclosed sensory and motor abnormalities in the left femoral and sciatic nerve distribution areas. The early performed lumbar CT scan did not show any complication and electromyographic evaluation performed on the ninth postpartum day was normal. Three months after delivery, some degree of neuropathic pain in the sciatic nerve distribution remained. The risk of neurological injury directly related to obstetrical positioning is discussed. Prolonged positioning using a posture which can induce nerve stretching should be avoided. This is especially true when the patient is receiving epidural analgesia which can mask pain or discomfort.
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Affiliation(s)
- L Ley
- Département d'anesthésie-réanimation, APHP, hôpital Antoine-Béclère, 92141 Clamart cedex, France
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33
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Borg-Stein J, Dugan SA. Musculoskeletal Disorders of Pregnancy, Delivery and Postpartum. Phys Med Rehabil Clin N Am 2007; 18:459-76, ix. [PMID: 17678762 DOI: 10.1016/j.pmr.2007.05.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Gender-specific care of musculoskeletal impairments is increasingly important in women's health. This is most relevant and of paramount importance as it relates to identification and management of musculoskeletal and peripheral neurologic disorders of pregnancy, delivery, and postpartum. The specific anatomic and physiologic changes of pregnancy predispose to a specific set of diagnoses. Virtually all women experience some degree of musculoskeletal discomfort during pregnancy. This article provides an overview of the more common pregnancy-related musculoskeletal conditions and includes a discussion of epidemiology, risk factors, diagnosis, prognosis, and management.
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Affiliation(s)
- Joanne Borg-Stein
- Physical Medicine and Rehabilitation, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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34
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Russell R. Neurological complications in obstetric regional anaesthesia. ANAESTHESIA & INTENSIVE CARE MEDICINE 2007. [DOI: 10.1016/j.mpaic.2007.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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35
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Ley L, Ikhouane M, Staiti G, Benhamou D. Complication neurologique après posture obstétricale «en tailleur» lors d'un travail sous analgésie péridurale. ACTA ACUST UNITED AC 2007; 26:666-9. [PMID: 17574376 DOI: 10.1016/j.annfar.2007.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Accepted: 04/03/2007] [Indexed: 11/17/2022]
Abstract
Obstetrical positioning is used more and more often because of the supposed or proven benefits although side effects are not well known. We therefore report the case of a patient who presented with a postpartum neurological deficit after a seven hour hip-flexed posture during labour under epidural analgesia. The parturient did not complain of pain or discomfort during labour. The neurological injury was suspected because of delayed recovery of epidural analgesia-induced motor block. Neurological examination disclosed sensory and motor abnormalities in the left femoral and sciatic nerve distribution areas. The early performed lumbar CT-scan did not show any complication and electromyographic evaluation performed on the ninth postpartum day was normal. Three months after delivery, some degree of neuropathic pain in the sciatic nerve distribution remained. The risk of neurological injury directly related to obstetrical positioning is discussed. Prolonged positioning using a posture which can induce nerve stretching should be avoided. This is especially true when the patient is receiving epidural analgesia which can mask pain or discomfort.
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Affiliation(s)
- L Ley
- Département d'anesthésie-réanimation, APHP, hôpital Antoine-Béclère, Clamart cedex, France
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36
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Tsen LC. What’s new and novel in obstetric anesthesia? Contributions from the 2003 scientific literature. Int J Obstet Anesth 2005; 14:126-46. [PMID: 15795148 DOI: 10.1016/j.ijoa.2004.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2004] [Accepted: 12/24/2004] [Indexed: 10/25/2022]
Abstract
THE PREGNANT PATIENT: Age; maternal disease; prophylactic antibiotics; gastroesophageal reflux; obesity; starvation; genotyping; coagulopathy; infection; substance abuse; altered drug responses in pregnancy; physiological changes of pregnancy. THE FETUS: Fetal monitoring; intrauterine surgery. THE NEWBORN: Breastfeeding; maternal infection, fever, and neonatal sepsis evaluation. OBSTETRIC COMPLICATIONS: Embolic phenomena; hemorrhage; preeclampsia; preterm delivery. OBSTETRIC MANAGEMENT: External cephalic version and cervical cerclage; elective cesarean delivery; fetal malpresentation; vaginal birth after cesarean delivery; termination of pregnancy. OBSTETRIC ANESTHESIA: Analgesia for labor and delivery; anesthesia for cesarean delivery; anesthesia for short obstetric operations; complications of anesthesia. MISCELLANEOUS: Consent; ethics; history; labor support; websites/books/leaflets/journal announcements.
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Affiliation(s)
- L C Tsen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston MA 02115, USA.
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