Caesarean delivery in T5 paraplegic following extended ICU stay in second trimester with absolute contraindication to neuraxial blocks

Abstract

Pregnancy in patients with spinal cord injury presents unique challenges to their care teams. While spinal cord injury alters the function of several organ systems, one of the most important consequences is autonomic dysreflexia. Anaesthesia providers must be familiar with the pathophysiology and management of gravid patients with spinal cord injury to manage their deliveries successfully. A multidisciplinary team is essential; close collaboration between the obstetrical and anaesthesiology teams is crucial. The authors will present a case of a successful caesarean delivery in a woman with a T5 injury as well as a recent epidural abscess using general endotracheal anaesthesia.

Background

Autonomic dysreflexia is a well-known phenomenon with spinal cord injury, most commonly described above the level of splanchnic sympathetic outflow, T6. The syndrome presents as significant elevations in blood pressure caused by unopposed sympathetic discharge as a reflex to stimuli from distention of a hollow viscus and the pubic area. The sympathetic discharge produces significant vasoconstriction. It is recognised by The American College of Obstetricians and Gynecologists as the most serious medical complication in women with spinal cord injury.¹ Pregnant patients with this condition usually get neuraxial anaesthesia early in labour to prevent the exaggerated response in vital signs.^2–5 Several case reports of successful pregnancies in women with paraplegia discuss the use of neuraxial blocks to manage their labour. Patients with spinal abnormalities, instrumentation and infection present a challenge to successful neuraxial blockade and are associated with an increased risk of complications. The authors will present a case report of a woman with a T5 injury with Harrington rods and recent epidural abscess found on MRI.

Case presentation

A 32-year-old G2P0010 woman with a history of sickle cell trait, paraplegia following a spinal cord injury at T5 after a motor vehicle accident in 1999, multiple spinal surgeries with placement of Harrington rods as well as multiple chronic decubitus ulcers presented to maternal–fetal medicine. She denied a history of autonomic dysreflexia. Her pregnancy was complicated by an Intensive Care Unit (ICU) admission for septic shock while early in the second trimester. At the time, she presented with dyspnoea and fever, found to have bilateral pleural effusions, left-sided empyema, methicillin-susceptible Staphylococcus aureus bacteremia, Escherichia coli UTI, T7/T8 epidural abscess and Pseudomonas pneumonia. Her treatment involved multiple intubations, antibiotics, chest tube placement and vasopressor support. During this hospitalisation, she was found to have a nonocclusive right internal jugular deep vein thrombosis (IJ DVT). A transthoracic echocardiogram performed during that admission was concerning for possible endocarditis. Biopsy of the epidural abscess was deferred due to the pregnancy and was treated conservatively with intravenous antibiotics. Progress of treatment was evaluated with serial thoracic MRIs. She remained on intravenous antibiotics for 3 months. Furthermore, she developed voice hoarseness following the intubations while in the ICU.

Investigations

Given the history of significant illness, several services were consulted prior to surgery. Cardiology found an enlarged right ventricle with mild dysfunction, moderate tricuspid regurgitation and a dilated, noncollapsing inferior vena cava on transthoracic echocardiogram. They attributed the RV dysfunction on the prolonged hospitalisation. The RV dysfunction placed her at risk for postdelivery RV failure and atrial arrythmia. They recommended diuretic administration immediately following umbilical cord crossclamping. Neurosurgery recommended against neuraxial anaesthesia given the epidural abscess.

Otolaryngology was consulted secondary to the patient’s hoarseness. They performed a videostroboscopy and found a posterior glottic gap with phonation and a thin and lateralised right vocal cord. They attributed this to a posterior scar likely from intubation trauma. They recommended further follow-up and a more extensive examination postdelivery.

Treatment

The following anaesthetic plan was developed after evaluating the patient with consideration to the consults. Given a multitude of factors, a caesarean delivery under general endotracheal anaesthesia was deemed to be the safest course of action. It was decided that neuraxial anaesthesia would be inappropriate given the Harrington rods, epidural abscess and chronic decubitus ulcers. A major concern was the potential for autonomic dysreflexia, which aided in the decision to deliver via caesarean. This would allow the anaesthesia team to control the many variables that may arise during delivery, in addition to avoiding spontaneous labour, which could precipitate an episode of autonomic dysreflexia. Careful blood pressure monitoring would be required, therefore, a preinduction arterial line would be placed. Cardiology is also requested to be present during the case to help manage diuretic therapy following delivery. Deep vein thrombosis prophylaxis was administered in accordance with American College of Obstetricians and Gynecologists (ACOG) guidelines. To reduce the risk of postoperative autonomic dysreflexia, bilateral transversus abdominis plane (TAP) or quadratus lumborum (QL) blocks were planned postoperatively. The patient would be admitted directly to the cardiac ICU following the procedure.

Intraoperative course

To closely monitor intraoperative and postoperative haemodynamics, a preinduction radial arterial line was placed with ultrasound guidance. The patient had a peripherally inserted central catheter (PICC) line in the right upper extremity. A large bore intravenous was desired for potential intraoperative resuscitation; however, intravenous access was very difficult in this patient. The decision was made to attempt additional intravenous after induction of anaesthesia to take advantage of the vasodilating effects of inhaled anaesthetics. All uterotonic agents were brought to the operating room. Placement of the foley catheter was deferred until after delivery to avoid precipitating autonomic dysreflexia. Once prepped and draped for surgery, and standard American Society of Anesthesiologists (ASA) monitors were in place, rapid sequence induction was performed with ketamine, propofol and rocuronium. Because of small mouth opening, the original plan of a CMAC-assisted intubation was abandoned, and the patient was intubated with a Mac three-blade and nonstyletted 6.0 tube to minimise vocal cord trauma. An entropy monitor was placed to ensure adequate depth of anaesthesia. A 16-gauge angiocatheter was placed in the left hand. Anaesthesia was maintained with sevoflurane and nitrous oxide. The cardiology attending was present during general anesthesia to assist with haemodynamic goals. The caesarean section was conducted according to standards of care with no operative complications. After umbilical cord clamping and no dramatic changes in haemodynamics, a dose of furosemide was given, and phenylephrine infusion was titrated to maintain systolic blood pressure in the 120–130 range. The foley catheter was placed at this time. The dose of furosemide was repeated for adequate response. Oxytocin was administered and uterine tone was noted to be adequate. Intravenous acetaminophen and ketorolac were given for pain control. Ondansetron was given for nausea prophylaxis. Though the patient was insensate below her original T5 injury, TAP blocks were placed with catheters to ensure decreased response to noxious stimuli. TAP infusions were continued postoperatively with ropivacaine 0.2% at 6 mL/hour. Neuromuscular relaxation was reversed with sugammadex and the patient was extubated uneventfully. She was transported to the CICU in stable condition and voice hoarseness noted to be unchanged. Apgar scores were noted to be 4, 7 and 8.

Outcome and follow-up

Postoperatively, the patient was transferred to the ICU where she remained haemodynamically stable. She was transferred to the postpartum floor on postoperative day 1. Because TAP blocks were used rather than neuraxial blocks (NAB), the patient was able to resume DVT prophylaxis at the discretion of the obstetrical (OB) providers. Her recovery was uneventful and she was discharged on postoperative day 3 after meeting discharge criteria, which is the standard length of stay for caesarean delivery at our institution. She was noted to be doing well at the 6-week OB follow-up visit.

Six weeks after delivery, she was seen by ENT to follow-up on her hoarse voice. They performed a videostroboscopy and noted that the cartilaginous right true vocal fold appeared to be abnormally shaped with incomplete posterior glottic closure, concerning for scar inferior to the right vocal process. They recommended an examination under anaesthesia with lysis of adhesions and Cymetra injection to enhance posterior glottic closure. At the time of completing this manuscript, she was scheduled to undergo the said procedure.

Discussion

While some women with spinal cord injury experience a transient amenorrhea, most resume regular menses and continue to maintain fertility.^{6 7} Those women who become pregnant require careful evaluation and management by a multidisciplinary team, which must include anaesthesiology. The most feared complication is autonomic dysreflexia, which can affect up to 85% of patients with lesions above the T6 level.⁸ Stimulation of hollow viscus, the genitalia or skin below the lesion may produce an exaggerated sympathetic response resulting in profound vasoconstriction producing the signs and symptoms seen in autonomic dysreflexia. The most common of these is hypertension.

If autonomic dysreflexia were to occur during labour, it may produce significant placental vasoconstriction, leading to fetal hypoxemia, bradycardia and acidemia. The labouring patient may experience severe complications from hypertension as well, including intraventricular haemorrhage, cerebral vascular accident, hypertensive encephalopathy, retinal haemorrhage and death.

To prevent autonomic dysreflexia in pregnancy and labour, early neuraxial anaesthesia is the common treatment of choice. The patient presented in this case report was an extremely poor candidate for epidural or spinal blockade due to vertebral instrumentation and confirmed epidural abscess. She was carefully evaluated by a multidisciplinary team and a perioperative plan was put in place. General endotracheal anaesthesia was determined to be the safest course of action. Although her caesarean delivery was uneventful and she did not experience the dreaded syndrome of autonomic dysreflexia, this case illustrates the importance of multidisciplinary collaboration and careful preoperative planning with attention to detail. Furthermore, it demonstrates that knowledge of the possibility of autonomic dysreflexia in this patient population as well as its pathophysiology and management is vital to all anaesthesiology providers.

Learning points.

• Autonomic dysreflexia is a phenomenon with spinal cord injury, above the level of splanchnic sympathetic outflow, T6. The syndrome presents as significant elevations in blood pressure caused by unopposed sympathetic discharge as a reflex to stimuli from distention of a hollow viscus and the pubic area.

• Autonomic dysreflexia is recognised by The American College of Obstetricians and Gynecologists as the most serious medical complication in women with spinal cord injury.

• Pregnant patients with spinal cord injury usually get neuraxial anaesthesia early in labour to prevent the exaggerated response in vital signs seen in autonomic dysreflexia.

• Anaesthesia providers must be familiar with the pathophysiology and management of gravid patients with spinal cord injury to manage their deliveries successfully.

• A multidisciplinary team is essential to evaluate and manage pregnant patients with spinal cord injury; close collaboration between the obstetrical and anaesthesiology teams is especially crucial.