Anesthetic considerations for liver diseases unique to pregnancy

Spinal subdural hematoma and subdural anesthesia following combined spinal-epidural anesthesia: a case report

Background

Subdural anesthesia and spinal subdural hematoma are rare complications of combined spinal-epidural anesthesia. We present a patient who developed both after multiple attempts to achieve combined spinal–epidural anesthesia.

Case presentation

A 21-year-old parturient, gravida 1, para 1, with twin pregnancy at gestational age 34^+ 5 weeks underwent cesarean delivery. Routine combined spinal–epidural anesthesia was planned; however, no cerebrospinal fluid outflow was achieved after several attempts. Bupivacaine (2.5 mL) administered via a spinal needle only achieved asymmetric blockade of the lower extremities, reaching T12. Then, epidural administration of low-dose 2-chlorprocaine caused unexpected blockade above T2 as well as tinnitus, dyspnea, and inability to speak. The patient was intubated, and the twins were delivered. Ten minutes after the operation, the patient was awake with normal tidal volume. The endotracheal tube was removed, and she was transferred to the intensive care unit for further observation. Postoperative magnetic resonance imaging suggested a spinal subdural hematoma extending from T12 to the cauda equina. Sensory and motor function completely recovered 5 h after surgery. She denied headache, low back pain, or other neurologic deficit. The patient was discharged 6 days after surgery. One month later, repeat MRI was normal.

Conclusions

All anesthesiologists should be aware of the possibility of SSDH and subdural block when performing neuraxial anesthesia, especially in patients in whom puncture is difficult. Less traumatic methods of achieving anesthesia, such as epidural anesthesia, single-shot spinal anesthesia, or general anesthesia should be considered in these patients. Furthermore, vital signs and neurologic function should be closely monitored during and after surgery.

Retrospective analysis of maternal, fetal, and neonatal outcomesof intrahepatic cholestasis of pregnancy at Gazi University

BACKGROUND/AIM

Maternal, fetal, and neonatal outcomes in parturients with intrahepatic cholestasis of pregnancy (ICP) have been retrospectively documented. We aimed to present pregnancy outcomes of parturients with ICP who underwent delivery. The study was conducted during a 1-year period.

MATERIALS AND METHODS

After ethics committee approval, data from 1 January to 31 December 2015 were collected to identify parturients with ICP.

RESULTS

Ten out of 37 patients underwent normal spontaneous vaginal delivery (NSVD), and the remaining 27 parturients underwent cesarean section (CS). Five of 27 parturients underwent nonelective cesarean section, while 22 had elective cesarean delivery. As for NSVD deliveries, only one parturient received combined spinal and epidural anesthesia (CSE) for labor. Neuraxial (n = 22 for spinal and n = 1 for CSE) and general anesthesia (n = 4) rates for CSs were 85% and 15%, respectively. Approximately 96% of neuraxial anesthesia choices were spinal anesthesia. Nearly 18.5% of CSs were not elective. Adverse outcomes included 2 preterm births, 2 preterm labors, 2 newborns with hepatitis, and one perinatal fetal death.

CONCLUSION

Parturients with ICP who had normal coagulation parameters despite increased liver enzymes preoperatively underwent cesarean delivery under spinal anesthesia without complication. Although maternal outcomes were generally positive, adverse fetal and neonatal outcomes are more likely to occur, particularly in cases with severe ICP.