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Spinal anaesthesia for Elective Caesarean Delivery in a parturient with Yellow Nail Syndrome
Abstract Number: T-58
Abstract Type: Case Report/Case Series
BACKGROUND: Yellow Nail Syndrome (YNS) is a rare syndrome of unknown aetiology presenting with 2 or more of the classic triad of lymphoedema, chronic respiratory disease and yellow nails. To our knowledge, there have been no reports describing the obstetric anaesthetic management of patients with YNS.
CASE REPORT: A 20 year old primigravida presented to our obstetric services at 20 weeks gestation with an unplanned singleton pregnancy. The patient had a history of Yellow Nail Syndrome (YNS) and displayed the classic triad of yellow nails, lymphoedema and respiratory manifestations including recurrent chylous effusions.
The patient was followed up regularly by a respiratory physician and at the time of presentation her only regular medications were anti-asthma inhalers and iron tablets.
She was reviewed in our high risk pregnancy clinic with ongoing review by the obstetric team. Blood tests revealed a mild microcytic anaemia and lymphopenia (Hb 106, Plt 256, WCC 9.5). Lung function tests demonstrated an FEV1 of 1.5L and FVC 1.7L (FEV1:FVC 88%). CT Chest showed basal atelectasis. She had an uncomplicated pregnancy and was admitted at 39 weeks for an elective caesarean section. Spinal anaesthesia was conducted with the patient seated, at the level of L3/4 with 2.4ml 0.5% heavy bupivacaine and 400 micrograms diamorphine. A healthy male infant was delivered with Apgar scores of 9 and 10 at 1 and 5 minutes. Post-operative blood loss was estimated at 700ml and duration of surgery was 95 minutes. Postoperative recovery was complicated by anaemia (Hb 84 g/dL) for which she received a 2 unit blood transfusion. Further recovery was uneventful and she was discharged at 48 hours.
DISCUSSION:Information on Yellow Nail Syndrome is limited. There are approximately 150 case reports or series in the literature but none describing the obstetric management of parturients.
Regional anaesthesia is the technique most familiar to anaesthetists (1). However, ventilatory compromise associated with YNS may necessitate a GA. This highlights the importance of adequate preassessment, investigation and optimisation for such patients within a multidisciplinary setting. No further preoptimisation was necessary but we suggest seeking advice from a respiratory physician as further investigations and procedures, such as thoracocentesis, may be appropriate in other cases. We found that gross lymphoedema of the lower limbs and back caused minor difficulties in positioning the patient and palpation of the relevant anatomy. Lymphoedema and chronic lung conditions may also predispose to local and systemic infections (2), which may contraindicate regional anaesthesia. These risks should be balanced against the benefits of GA and postponement of the procedure if indicated.
1. Djabatey EA, Barclay PM. Anaesthesia. 2009 Nov;64(11):1168-71
2. Maldonado F, Ryu JH. Curr Opin Pulm Med. 2009 Jul;15(4):371-5