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Bell’s palsy Post-Partum- Did the Epidural play a role?
Abstract Number: SA-52
Abstract Type: Case Report/Case Series
Bell’s palsy, also known as idiopathic facial nerve palsy, is characterized by acute onset of unilateral facial paralysis due to neuropathy of the seventh cranial nerve. We present the case of a patient who underwent uneventful combined spinal/epidural labor analgesia and developed acute onset facial weakness two days post-partum.
A 29 yr old G3P2 underwent induction of labor at 37 weeks’ gestation for intrahepatic cholestasis of pregnancy. She underwent an uncomplicated combined spinal epidural block and received programmed intermittent epidural boluses for maintenance of labor analgesia. Ten hours later she had a spontaneous vaginal delivery. The patient noted numbness on the left side of her tongue 12 hrs after delivery. On postpartum day 2, she was discharged home but then developed left facial droop, difficultly moving her mouth, and decreased facial sensation on the left side. On examination, she had intact pupillary reflexes, left facial droop, decreased left facial sensation, lack of forehead wrinkling, and incomplete left eye closure. The patient denied headache, visual changes, tinnitus, nausea, or vomiting. She was discharged home with acyclovir, prednisone, eye lubricant, and eye patching with follow up from obstetric anesthesia and obstetric providers.
Postpartum Bell’s palsy following neuraxial labor analgesia has been poorly described with only isolated case reports. Bell’s palsy is the most common cause of unilateral facial paralysis with a rate of 17:100,000 in the general population and 40:100,000 in the pregnant population.1 Herpes simplex virus re-activation in the geniculate ganglion, which occurs more frequently post-partum, is the most likely cause. The anesthetic technique in labor may play a role in the development of this disorder. Intrathecal morphine has been shown to increase herpes reactivation and may precede development of Bell’s palsy postpartum, yet our patient did not receive intrathecal morphine.2 There are case reports of post dural puncture headache induced cranial nerve palsies, secondary to traction on cranial nerves from CSF leak. Our patient did not demonstrate headache symptoms, positional or otherwise. Epidural blood patches have also been implicated in cranial nerve palsies, possibly related to increased pressure translocating up the epidural space. Another possible etiology includes pressure induced facial nerve injury from increased fluid balance in term and immediate post-partum parturients, specifically in patient suffering from preeclampsia.3 Postpartum follow up is recommended to monitor resolution of symptoms. If the presentation is atypical or symptoms have not improved after four months, then imaging and EMG studies are recommended to exclude other causes, such as malignancy.3
1. Ann Otol Rhinol Laryngol 1975;84:433-42
2. Anesth Analg 2005;100:1472–6
3. Otolaryngology–Head and Neck Surgery 2007;137,858-861