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Cesarean section in a parturient with lumboperitoneal shunt for symptomatic idiopathic intracranial hypertension
Abstract Number: F-52
Abstract Type: Case Report/Case Series
Introduction: Ideopathic intracranial hypertension (IIH) is a disorder of unknown etiology with incidence of 1-4:100000 in obese women of childbearing age. We describe the anesthetic management for cesarean section in a parturient with lumboperitoneal shunt (LPS) and symptomatic IIH.
Case: A 20 years old nulliparous caucasian woman with body mass index 36kg/m2 and known IIH with LPS was referred to anesthetic antenatal clinic at 26 weeks of gestation. She was treated with furosemide, acetazolamide and repeated lumber puntures followed by insertion of LPS prior to conception for her symptoms mainly headache and diplopia. A decision was made for cesarean section at 36 weeks of gestation due to worsening symptoms of constant headache, diplopia, visual disturbances, retro orbital pain, tinnitus and papilledema. Anesthetic assessment revealed a potential difficult intubation with mallampati class 3 airway. She had a hypertrophic paramedian scar on her back from 2nd to 5th lumber vertebrae due to LPS. Decision for GA with invasive monitoring, transversus abdominis plane (TAP) block were discussed in detail with her. An arterial line was used for invasive monitoring. Her baseline heart rate 85-95 beats/min, blood pressure 135-140/80-85 mmHg and SpO2 96-98% on room air were noted. After intravenous cefuroxime 1.5 gm and pre-oxygenation, 1μg/kg bolus of remifentanil was given over 30 seconds prior to rapid sequence induction with thiopentone (5mg/kg) and suxamethonium (1.5mg/kg). The neonatal team were informed about using remifentanil. She was grade 2a intubation with size 7 tracheal tube. A 3250 g female infant was born who remained apnenic for 6 min required bag mask ventilation by neonatologist. 40 U of oxytocin was administered via syringe pump. Estimated blood loss was 1000 ml and her heart rate and blood pressure remained stable and close to her baseline level throughout the procedure. Abdominal cavity was washed with warm saline prior to closure and paracetamol, morphine and ultrasound guided TAP block with 25 mls of 0.25% bupivacaine at each side were given for pain relief. She was admitted to high dependency unit after extubation and her neurological symptoms started to improve 6 hrs postpartum with complete recovery over 48 hrs after delivery.
Discussion: Shunt malfunction secondary to uterine enlargement during pregnancy and obstruction from clots after cesarean is also possible(1). Neuraxial anesthesia in IIH with LPS can be challenging and risk of shunt damage, introduction of infection and worsening neurology were the main concerns for us to consider GA in this case(2). A bolus of 1μg/kg remifentanil effectively attenuates hemodynamic changes on induction however, crosses the placenta and may cause neonatal depression.
1. Samuels P. Cerebrospinal fluid shunt in pregnancy. Am J Perinatol 1988;5:22-25.
2. Aly EE, Lawther BK. Anesthetic management of uncontrolled IIH during labour and delivery. Anesthesia 2007;62:178-8