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IS THE PATIENT HAVING A STROKE?
Abstract Number: F-29
Abstract Type: Case Report/Case Series
Introduction: Labor and Delivery is a dynamic unit where things happen quickly. A case of ptosis one hour after epidural analgesia in a hypertensive patient resulted in a stat page for the Stroke Team and extensive work-up.
Case Report: A 32 year old G4P3003 BMI 35 with chronic hypertension for induction of labor at 37 weeks for suspected preeclampsia. Despite labetalol 200mg BID, BP 160/100. Uncomplicated epidural with 10mls 0.25% bupivacaine and continuous infusion of 0.0625% bupivacaine with fentanyl at 12mls/hr. An hour later, the husband noticed drooping of his wife’s right eyelid. The OB resident noted BP 180/110, right ptosis, no other findings. The Stroke Team came, sent patient to MRI,epidural catheter removed, not MRI compatible. Thirty minutes after onset, ptosis resolved, patient had no deficits. No acute cerebrovascular or intracranial process. Three hours later epidural reinserted, no ptosis developed. A healthy boy was delivered spontaneously. She was discharged 2 days later. She was informed that the ptosis was due to transient Horner’s syndrome sometimes seen during epidural anesthesia.
Discussion: Possible stroke had to be ruled out since her blood pressure rose further with anxiety. Clayton found an incidence of 1.3% of Horner’s with labor epidural and 4% of patient undergoing a cesarean section, suggesting the volume of local anesthesia is a critical factor. The OB team, unaware that Horner’s syndrome can occur with epidural, was understandably concerned about stroke. Since the epidural was discontinued, ptosis and other signs and symptoms of Horner’s syndrome resolved. BPs returned to baseline when stroke was ruled out. Horner’s or occulosympathetic palsy was first described in 1869, consists of ipsilateral miosis, ptosis,enophthalmos, flushing of the face, anhydrosis, and conjunctival injection. When associated with epidural anesthesia, it is benign, self-limiting and resolves without treatment. It is possible for Horner's to be associated with more serious medical conditions and should be investigated if it does resolve in a few hours. Anatomical and physiological changes during pregnancy favor cephalad spread of local anesthesia when engorgement of epidural veins compress the epidural space.Ferromagnetic wires and catheters are not MRI compatible. We conducted an in vitro study to determine what happens if they are subjected to MRI. All guide wires and epidural fragments migrated to MRI head at an alarming rate of ~50 cm/hour