neurological complications of the parturient complications of the parturient-1.pdfother types of...
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Neurological
Complications of the
Parturient
M. Roseann Diehl, CRNA, DNP, PhDc
Sanford Health, Fargo, ND
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Pre-existing
pathophysiological
condition
Complication of
labor
Complication of
neuraxial anesthesia
Neurological injury
Pathophysiological
condition induced by
pregnancy
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Most Common Neurological Issues
• Antepartum • Headache
• Seizures
• Pre-existing neuropathies
• Postpartum • Headache
• Seizures
• Lower back pain
• Lower extremity numbness
Obstetric neuropathy 1-9
out of every 1,000 births
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Physiological Changes of Pregnancy
blood
volume 40-
50% (HTN)
progesterone
(enhances venous
distensibility/vessel leakage)
estrogen (stimulates
clotting factors)
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Neurological changes
Manijeh & Varner (2013). Clinical Obstetrics and Gynecology, 56(2), 330-341
Cipolla (2013). Journal Cerebral Blood Flow & Metabolism, 33(4), 465
Cerebral vascular resistance
Cerebral blood flow (22% 3rd trimester)
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Headaches • Primary disorder (20%)
• PDPH (81%) after accidental dural puncture • accidental dural puncture (0.6%-1.3%)
• Intracranial hypotension
• Subdural placement of catheter
• Pseudotumor cerebri (primary idiopathic intracranial hypertension)
• CNS disorders
• Pneumocephalus
• Cerebral venous thrombosis
• Subdural hematoma
• Posterior reversible encephalopathy syndrome
MacGregor. Headache in Pregnancy, Continuum Journal. 2014, 128-147.
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Case One Healthy 28-year-old primagravida
Epidural attempted, dural puncture
Intrathecal catheter placed
Good analgesia
DC’d 24 hours after delivery
6 hours later postural headache
Placed blood patch
Discharged home next day, 3 days later headache returns
Another blood patch relieves headache
2 days later headache returns—stronger & more progressive (worse
when standing +N/V +diplopia)
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International Headache Society
Definition of PDPH
Bilateral
Develops within 7 days of lumbar puncture
Worsens within 15 minutes of upright position
Improves within 30 minutes of horizontal
position
PDPH develops in more than 50%
Apfel, et al. Prevention of PDPH after accidental dural puncture: a quantitative systematic review.
British Journal of Anaesthesia, 2010;105(3):255-63.
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Post-dural puncture headache
At risk population: larger needles, cutting
needle, youth, pregnant
Symptoms: frontal occipital headache that
worsens with standing/sitting and gets better
when lying
Associated symptoms:
Pain radiating to neck, photophobia, neck stiffness, nausea,
diplopia, tinnitis
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Blood patch issues
Volume of blood?
Pt activity at home?
Multiple attempts?
CSE?
Success of epidural blood patch First blood patch 60-70%
Second blood patch >90%
If two were unsuccessful then need further investigation/neurological
consult
20mL minimum
Information sent with patient
home
Paech, et al. The volume of blood for epidural blood patch in obstetrics: A randomized, blinded clinical
trial. Anesthesia Analgesia, 2011;113(1): 126-33.
Accompanying symptoms
Nausea/vomiting
Visual disturbances (14%)
Hearing alteration (10%)
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Prevention of PDPH after ADP Conservative measures are often not effective
Common interventions studied to minimize risk of PDPH:
Epidural morphine (3mg after delivery, 3mg before catheter removal)
Prophylactic blood patch (5-20 mL)
Intrathecal catheter placement (24 hours)
Dexamethasone (8-10 mg)
Cosyntropin (1mg IV)
Evans, et al. Assessment: prevention of PDPH. Report of the therapeutics and technology assessment subcommittee of the
American Academy of Neurology. 2000;55:909-914.
Apfel, et al. Prevention of PDPH after accidental dural puncture: a quantitative systematic review. British Journal of Anaesthesia,
2010;105(3):255-63.
Interventions may be helpful, but underpowered and/or poorly studied with results that
have not been reproducible.
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Cosyntropin 1 mg IV
RCT, N=95
Cosyntropin or 0.9% saline given 30 minutes
after delivery/epidural DC’d.
All PDPH were managed conservatively for 48
hours, then EBP, a second EBP was
performed after another 24 if needed
Cosyntropin (33%) suffered PDPH vs control
(69%) [P= 0.001]
Hakim. Cosyntropin for prophylaxis against PDPH after ADP. Anesthesiology, 2010;113(2):
413-420
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Case One Healthy 28-year-old primagravida
Epidural attempted, dural puncture
Intrathecal catheter placed
Good analgesia
DC’d 24 hours after delivery
6 hours later postural headache
Placed blood patch
Discharged home next day, 3 days later headache returns
Another blood patch relieves headache
2 days later headache returns—stronger & more progressive (worse
when standing +N/V +diplopia)
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Diplopia: Abducens Nerve Palsy
Magierlo et al. Ginekol Pol. 2014;85(1):58-61
Zupan et al. CMJ. 2012;53:379-85.
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CTbilateral subacute SDH
MRI right parietal cortical
venous thrombosis
Magierlo et al. Ginekol Pol. 2014;85(1):58-61
Zupan et al. CMJ. 2012;53:379-85.
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Cerebral venous sinus thrombosis
Rare
Third trimester/postpartum
Underlying thrombophilia?
Headache progressively worse or sudden
thunderclap headache
Incidence is higher in
underdeveloped countries
due to higher frequency of
poor nutrition and increased
risk of CSF hypotension
Edlow, et al. (2013). Lancet 12, 175-185
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Cerebral Venous Thrombosis
CVT
Incidence: 1:10,000 – 1:25,000 or (0.0001% – 0.00025%)
65% cases pregnancy-related Most common in postpartum
Venous sinus damage from ICP flux
Pregnancy-induced hypercoagulable state
Often preceded by an intense H/A (thunderclap) McCaulley, Pates. Postpartum cerebral venous thrombosis. Obstetrics & Gynecology, 2011;118(2,Part 2):
423-425.
Haider, et al. Neurological disorders. Best Practice & Research Obstetrics & Gynecology, 2013;27:867-875.
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CVT
Symptoms
*Positional H/A
Dizziness
Nausea/vomiting
Blurred vision
*One-sided weakness
Lethargy
*Seizures
Coma McCaulley, Pates. Postpartum cerebral venous thrombosis. Obstetrics & Gynecology, 2011;118(2,Part 2):
423-425.
*Significant and commonly observed CVT symptoms
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Case Two
Pneumocephalus
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Air vs saline? Most frequently cited complications
Difficult catheter insertion
Paresthesia
Intravascular catheter insertion
Accidental dural puncture
PDPH
Patchy block
Dilute local anesthetics
Slow onset of local anesthetics
Heesen et al. Can the incidence of accidental dural puncture in laboring women be reduced? Systematic
review and meta-analysis. Minerva Anestesiologica 2013;79(10): 1187-97.
Schier, et al. Epidural space identification: A meta-analysis of complications after air versus liquid as the
medium for loss of resistance. Anesthesia Analgesia, 2009;109(6), 2012-2021
No significantly different complication rate between the 2 techniques
Focus on measures to reduced severity of PDPH once dural puncture occurs
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Pneumocephalus
Air LOR
Acts as a space-occupying lesion
Headache, sore/stiff neck, nausea/vomiting,
blurred vision, tinnitus, dizziness, seizures,
depressed LOC
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Pneumocephalus
Volume of air (3-40 mL)
Immediate or delayed
Classic symptoms
Sudden severe H/A
Often shooting from neck to forehead
Not necessarily postural in nature
Diplopia
Dilated pupils
Neuro changes
Motor deficits
(Resolves after air absorption and conservative
treatment)
Smarkusky, et al. Obstetrics & Gynecology, 2006
Kowe & Waters, Neurology Clinics, 2012
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Reversible Cerebral Vascular
Syndrome
First reported in 1988
Also, known as postpartum angiopathy
(within 1 week after delivery)
Call-Fleming syndrome
8-39% also have PRES
Abrupt onset thunderclap headache
(associated with photophobia) Edlow, et al. (2013). Lancet 12, 175-185
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Posterior reversible encephalopathy
syndrome
Accompanies eclampsia, HTN, renal disease,
sepsis
Postpartum
Headache, seizures, visual disturbances
(diplopia)
Vasogenic edema
MRI focal edema Edlow, et al. (2013). Lancet 12, 175-185
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Case Three
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Epidural catheter within subdural space
Reina, et al. Unintentional subdural placement of epidural catheters. Regional Anesthesia & Pain Medicine, 2011;36:537-
541
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Subdural injection characteristics
Hoftman. Unintentional subdural injection. Anesthsiology Clinics, 2011;29:279-290
Reina, et al. Unintentional subdural placement of epidural catheters. Regional Anesthesia & Pain Medicine, 2011;36:537-
541
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Lessons Learned?
Other types of postpartum headaches
• Primary (migraines, tension)
• Secondary (CVT, reversible cerebral
vasoconstriction syndrome, stroke,
intracranial hematomas, meningitis, tumors,
posterior reversible encephalopathy
syndrome (PRES)
Edlow, et al. (2013). Lancet 12, 175-185
Additional Lessons:
• Detailed neurological evaluation for a failed
epidural blood patch
• Progressively worse headache (thunderclap?)
• Look for diplopia or blurred vision
• Air or saline used for epidural placement?
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Neuraxial Hematoma
32 year-old membranes spontaneously
ruptured, repeat C-section
SAB placed without incident
3rd day postoperatively lower back pain and
worsening lower extremity weakness
Emergency laminectomy/evacuation
hematoma
Madjugiri, et al. BMJ Case Reports, October 29, 2012
Bateman, et al. Anesthesia Analgesia, 2013;116:1380-85
Incidence Epidural Hematoma < 1 in 150,000
Incidence even lower in the obstetric population
Neuraxial hematomas in obstetric patients occur with existing coagulopathies
Epidural hematomas occur in setting of INR > 1.5 when catheter inserted/DC’d
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Epidural hematoma
1: 150,000 to 1: 200,000
Suspect if:
• Longer lasting epidural
• Unusual back pain/tenderness
• Persistent numbness
• Motor weakness
• Sphincter dysfunction Kowe & Waters. (2012) Neurology Clinics, 30, 823-833
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Epidural abscess
1:500,000
1: 39,000
Kowe & Waters. (2012) Neurology Clinics, 30, 823-833
Meningitis
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Case Four
30-year-old female G3P2 scheduled for a repeat C-
section under SAB
27g pencil tip inserted L2-L3
Pt complained of pain down right leg
Good CSF flow (no pain on injection)
8 hours later complained of throbbing pain radiating down
right leg with weakness, toe paresthesia, and numbness
on whole of right leg.
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MRI no abnormality, but
small syrinx
Conus medullaris lesion
Resolved 3 months later
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Conus Medullaris
80% population cord ends at L1
20% population cord ends at L2
Broadbent, et al (2000). Ability of anesthetists to identify a marked lumbar interspace. Anaesthesia, 55, 1122-6.
• Cord may extend as low as L3
• No constant relationship to iliac crest lining up with L4
• At level of the conus nerve roots form a lattice in close
proximity to the cord with arachnoid membrane
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Neuraxial complications
Damage to conus medularis
Pain with needle placement and/or injection
Reynolds F. Damage to the conus medullaris following spinal anaesthesia.Anaesthesia 2001; 56: 235–47
Reynolds F. Damage to the conus medullaris following spinal anaesthesia.Anaesthesia 2001; 56: 235–47
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Obstetric surface anatomy affecting
conus:
Pencil tip can have 1mm of blind tip
Mis-identification of correct space
Iliac crest line more cephalad
Needle orientation angling cephalad
Frank. (2008). Journal of Emergency Medicine, 35(2), 149-157.
Lessons Learned:
Always respect a paresthesia
Double check level
See if there is a lower interspace
Watch angular orientation of needle
Replace stylette before removal to ensure nerve
tissue pushed away from bevel
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Case Five
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Postpartum nerve injuries
0.008%-0.5%
0.92%
Wong, et al. Obstetrics & Gynecology, 2003;101(2):279-85
Wong et al. Best Practice & Research Obstetrics Gynecology,2010;24:367-381
Sanford (2013) had 2,524 deliveries
That’s potentially 23 nerve injuries in one
year!
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Postpartum nerve injuries
Kowe, Waters. Neurological complications of obstetric anesthesia. Neurology Clinics, 2012;30: 823-833
Labor-related:
Prolonged 2nd Stage
Labor
Instrumentation
Pushing time
Thigh flexion, abduction,
and external rotation
Intrinsic Injuries
Nulliparity
Morbid obesity
T2DM
Neuromuscular disease
Anesthesia-related
•Direct trauma
•Low conus medullaris
•High needle placement
•Cord trauma
•Dural puncture(CN VI, VIII)
•Traumatic catheterization
•Indirect trauma
•abscess, hematoma
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Postpartum Neurological deficits
Contributing factors
Instrumental delivery
Short stature
Prolonged labor
Primiparity
Persistent transverse/posterior fetal position
Prolonged lithotomy during labor
Kowe & Waters. (2012) Neurology Clinics, 30, 823-833
Stretch & compression of lateral
femoral cutaneous nerve
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Postpartum Neurological Deficits
Neuraxial causes
• Direct trauma to cord o low conus medullaris
o traumatic catheterization
o high needle placement
• Indirect trauma o hematoma
o abscess
• Meningitis
• Spinal cord ischemia
• Cauda equina syndrome
• Others o Dural puncture/CSF leak
o Total spinal block
o Back pain
o Seizures (systemic toxicity)
o Pneumocephalus
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At risk for peripheral nerve injury
No superior technique/Avoid high injection pressures
Be aware of comorbid conditions increasing nerve injury
risk: • Diabetes
• Severe peripheral vascular disease
• Chemotherapy
• Multiple sclerosis
• Paresthesia elicited
• Nulliparity
• Labor progress
• Obesity
10-27 per 10,000
deliveries
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Back Pain
SAB 15%
Epidural 30%
Pain is self-limiting
Early symptom of epidural hematoma/abscess
Causes: multiple attempts/ligamentous
sinjury, periosteal trauma, local inflammation
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Birth Trauma (Obstetric Palsies) Palsy Manifestations Possible Cause
Lateral femoral cutaneous (L2-L3) Sensory: Anterolateral thigh
numbness
Prolonged pushing in lithotomy
Femoral (L2-L4) Sensory: Anterior thigh/medial
leg/calf & foot numbness
Motor: weak hip flexion & knee
extension, patellar reflex
Prolonged pushing with hips
excessively flexed
Lumbosacral plexus(L1-S4) Sensory: Lateral leg and dorsum
foot
Motor: foot drop
Fetus head against posterior rim of
pelvic bone, forceps delivery
Common peroneal Sensory: Anterolateral leg and
dorsum foot
Motor: foot drop
Prolonged pushing in lithotomy;
mother’s hands on lateral knees
Obturator (L2-L4) Sensory: Inner thigh and knee
numbness,
Motor: Thigh adduction
Fetal head compression on lateral
pelvic wall, forceps delivery
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Lateral Femoral Cutaneous
Meralgia Paresthetica
Lateral aspect of thigh
Burning, uncomfortable pain, tingling
numbness
No motor involvement
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Femoral
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Peroneal Neuropathy
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Obturator
Numbness/pain over groin
Adductor weakness
Months to resolve
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Metabolic Neuropathies
B12 deficiency post-bariatric surgery
Thyroid disorders
Diabetes
Lower extremity limb weakness (calves)
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Case Six
• 25 year-old G2P1, 39 weeks
• Active labor
• Epidural placed without problem
• Test dose 3mL (1.5% lidocaine with epi)
• 10 mL bolus then gtt started at 8 mL/hr
• An hour later the OB nurse calls
• Left side face “feels funny”
• Miosis/ptosis
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Horner’s syndrome after epidural
• Incidence greater in parturients
• Constellation of symptoms • Miosis
• Ptosis
• Anhydrosis
• Ipsilateral facial flushing
• Sympathectomy
• Mean time of onset: 25 minutes post-insertion
• Mean duration: 3.5 hours
Incidence
0.4% - 2.5% (epidural)
4% (epidural C/S)
Lynch et al. Horner’s syndrome following epidural analgesia for labor, Journal of the American Board of Family
Medicine, 2006; 19(5), 521-534.
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Bell’s palsy
0.017% pregnancy and puerperium
50% recovers within weeks -months
Klein, Clinical Obstetrics & Gynecology, 56(2), June 2013, 382-388
Damage to CN VII
Begins/worsens over 3-5 days
Associated with
T2DM
Increased BP
Trauma
Toxins
Lyme disease
Guillian-Barre
Sarcoidosis
Myasthenia gravis
Infection
Symptoms:
Loss feeling
Headache
Tearing
Drooling
Taste change
Hypersensitive
to sound
Cannot close
eye on affected
side
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Post-Partum Assessment
Timing/onset of symptoms?
Location/severity of symptoms?
Are the symptoms progressing/regressing?
Do they radiate?
Did the patient receive neuraxial anesthesia?
Was there any paresthesia with neuraxial placement?
Was there full recovery from neuraxial anesthesia?
What was the duration of labor?
How long was the patient pushing in lithotomy?
Was any instrumentation used?
Visual changes
Back pain
Injection site
Signs of infection
Laboratory values
Medications
Pre-existing co-morbidities
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Carpal Tunnel Syndrome
Numbness/tingling over hand/thumb
Pain increased at night
Not always relieved after pregnancy
Klein, Clinical Obstetrics & Gynecology, 56(2), June 2013, 382-388
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Liability and OB Anesthesia
Davies, et al. Liability associated with obstetric anesthesia. Anesthesiology, 2009;110(1):131-9
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Liability and OB Anesthesia
Davies, et al. Liability associated with obstetric anesthesia. Anesthesiology, 2009;110(1):131-9
Wong, et al. Best Practice & Research Obstetrics and Gynecology, 2010;24:367-381
37% claims were for minor injuries (e.g., headache, pain during anesthesia, back pain
and emotional distress)
21% claims were for nerve injuries
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Keeping everyone happy can be
difficult…
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Thank you!
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Headache
Woitzik J, Barth M, Tuettenberg J. Persistent postpartum headache from a chronic subdural hematoma after peridural
anesthesia. Obstet Gynecol. 2006;108:808–809.
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Headaches and Preeclampsia connection
80% complain of headache
“shining forth”
flashing lights
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Edlow, Caplan, Obrien, Tibbles. (2013) Lancet Neurology, 12, 175-185.
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Edlow, Caplan, Obrien, Tibbles. (2013) Lancet Neurology, 12, 175-185.
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Pre-eclampsia (2-8% all pregnancies)
Defined: new onset HTN and proteinuria after
20 weeks in a previously normotensive
woman
Mild: BP > 140/90 and proteinuria > 3g/24h
Severe: BP >160/110 ( 2 times > 6h apart)
and proteinuria > 5g/24h
Edlow, et al. (2013). Lancet 12, 175-185
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Pre-eclampsia & Seizures
Mild 0.6%
Severe 2-3%
Mortality for eclampsia is brain ischemia or
hemorrhage
Edlow, et al. (2013). Lancet 12, 175-185
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Pre-eclampsia (Questions???)
How is BP?
Laboratory values
Proteinuria
End-organ issues (renal, CV, pulmonary)
Labor progress (discussion with OB)