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Spinal anesthesia for emergency Cesarean delivery in a parturient with malaria falciparum
Abstract Number: S-59
Abstract Type: Case Report/Case Series
Introduction: In the United Kingdom (UK) there are approximately 1500 cases of imported malaria a year. Despite malaria being a common disease world-wide, this is the first report of neuraxial anesthesia for cesarean delivery (CD) in a parturient with confirmed severe falciparum malaria.
Case report: A 35 year old Nigerian parturient (G3P2) with no medical history presented at 35 weeks gestation with fever, rigors, vomiting and headache. She had recently arrived in the UK from Nigeria. On admission a blood film was performed confirming falciparum malaria, with a parasitaemia of 3.8%, a level consistent with severe infection. Intravenous quinine therapy was started and she began spontaneous labor 48 hours later. Following labor onset, continuous cardiotocography displayed 2 late deep decelerations and a decision was made for emergency CD (category 2) in view of potential fetal compromise. She was hemodynamically stable and lab investigations revealed a platelet count of 119 x 10 /L, INR 1.1 and APTT 30.8 s. Spinal anesthesia at the L4/5 interspace was performed with intrathecal injection of 12 mg of hyperbaric bupivacaine and 400 micrograms of diamorphine using a 25 G Whitacre spinal needle. Surgery was uneventful with no cardiovascular instability and a healthy neonate (3850 g) was delivered. On day 1 post CD repeat blood film microscopy showed a malaria parasitaemia of <0.01%. Mother and baby were discharged home on day 3 following CD with no further complications reported at 1 month.
Discussion: An estimated 25% of women in sub-saharan Africa have malaria during pregnancy.(1) UK treatment guidelines issued by the Royal College of Obstetricians and Gynaecologists do not provide recommendations regarding anesthetic technique for CD in such patients. Spinal anesthesia has previously been used without complication in a parturient with babesiosis, a disease also characterised by intraerythrocytic parasites.(2) Spinal anesthesia in this patient was chosen after exclusion of coagulopathy and discussion with an infectious diseases expert. Although spinal anesthesia poses a theoretical risk of the needle introducing erythrocytes containing malaria parasites into the cerebrospinal fluid (CSF) and precipitating cerebral malaria, it was felt that the risk of parasite transfer into the CSF was low and unlikely to cause complications since cerebral malaria results from sequestration of malaria parasites in brain capillaries rather than being a meningeal process. We feel that spinal anesthesia is not contraindicated in parturients with malaria provided a clear risk-benefit analysis has been made. Further work is required to elucidate the safety of neuraxial anesthesia in this setting.
1. Desai M et al. Lancet Infectious Diseases 2007; 7: 93–104.
2. Sultan P et al. Anaesthesia 2012; 67:180-3.