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Transient Loss of Consciousness after Spinal for Cesarean without Hemodynamic or Respiratory Compromise
Abstract Number: T-60
Abstract Type: Case Report/Case Series
Case Report: A 33 year-old woman presented at 37 weeks for elective primary cesarean due to myomectomy four years prior. She had no other medical history. She had no allergies and took only prenatal vitamins. Physical exam showed only an anxious woman with hemodynamic s, complete blood count, electrolytes, within expected values. She was given metoclopramide, ondansetron , and cefazolin. Prior to spinal administration, vitals were recorded as blood pressure of130/80mmHg, heart rate of 90bpm, oxygen saturation of 99% on room air, and normal sinus rhythm. Spinal anesthesia was administered with 1.4mL of 0.75% bupivacaine. The patient was immediately laid supine and vitals measured as blood pressure of 145/58mmHg, heart rate of 110bpm, oxygen saturation of 100% on room air, and sinus tachycardia. After two minutes, we confirmed a T4 level block. The patient then expressed extreme anxiety– within seconds she closed her eyes her head tiled to the left. She was unresponsive to verbal command or taps to her glabella.
An evaluation of her vitals revealed a blood pressure of 157/57mmHg, heart rate of 112 bpm, oxygen saturation of 100% on room air, and a rhythm of sinus tachycardia. A circuit mask applied to her face demonstrated spontaneous tidal volumes of approximately 300mL at a rate of 10 to 12 per minute with a saturation of 100%. No medications were administered. Approximately two minutes after the initial unconsciousness, the patient began to rouse. After her episode of syncope was explained to her, she described hearing about possible intubation, which had been indeed discussed in the immediate moments of her unconsciousness. Other than anxiety and nausea, she did not describe any chest pain, shortness of breath, abdominal pain, or any other symptoms. The patient’s entire loss of consciousness lasted approximately three minutes.
When deemed appropriate, the obstetrician continued with the cesarean and a viable male infant was delivered with APGARs of 9. The patient had no difficulties for the duration of the case and remained hemodynamically stable throughout. She was discharged to home four days later, a standard length of stay on the labor and delivery unit, without any further incident during her admission.
Discussion: We can eliminate vasomotor and autonomic aberrations or direct cardiac events in our patient because she remained hemodynamically stable during the entire course of her loss of consciousness. The diagnosis of exclusion is hysterical fainting, which is characterized by the near or complete loss of consciousness, loss of motor tone, tachypnea, and closed eyes, with normal hemodynamics and blood glucose, often in response to an emotionally demanding event.
It is important to quickly consider a diagnosis of hysterical fainting in order to prevent an instinctive action to reverse any hemodynamic instability perceived to be a causative factor in the loss of consciousness.