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Anesthetic Management of Labor and Intrapartum Cesarean Delivery in a Patient with Conversion Disorder
Abstract Number: T-66
Abstract Type: Case Report/Case Series
Introduction: Conversion disorder is a psychiatric disorder involving altered sensory and/or motor function that cannot be explained by organic mechanisms. Conversion events occur in 4 to 12 of 100,000 patients yearly, with the overwhelming majority occurring in young adult females during times of stress.1 Pregnant women with conversion disorder can pose a challenge for an obstetrical anesthesiologist. A concomitant episode of conversion disorder while undergoing a neuraxial anesthesia may present a confusing clinical picture, considering that neuraxial anesthesia, its complications, and conversion episodes may manifest with overlapping and dramatic motor and sensory elements.
Case Description: Our patient had a history of conversion disorder, which manifested as loss of consciousness. She presented for induction of labor for pre-eclampsia. A labor epidural catheter was placed at the patient’s request after confirmation of normal hematological laboratory values. After an extended period of no cervical change, the decision was made to proceed with an intrapartum cesarean delivery. At that time, epidural analgesia was found to be ineffective. 45 minutes were allowed to elapse to permit local anesthetic resorption from the neuroaxis, and then a spinal anesthetic was performed in the operating room. One minute after induction of the subarachnoid block, she complained of leg weakness and her eyes closed. Her lid response was absent and she was unresponsive to verbal or painful stimuli to her extremities. Her ventilation was infrequent, but vital signs were stable with no evidence of bradycardia or significant hypotension. Spontaneous ventilation was maintained with supplemental oxygen by facemask. A conversion episode was diagnosed and a high spinal block was ruled out based on the lack of apnea or hemodynamic perturbations. Given her lack of return in mental status, inability to assess the adequacy of spinal anesthesia, and apparent inability to cope with psychologically stressful situations, a decision was made to proceed with cesarean delivery under general anesthesia.
Discussion: We highlight the challenges surrounding obstetric and anesthetic management of a parturient with conversion disorder. Stringent avoidance of general anesthesia in these cases may not always be warranted, and a balanced view of all anesthetic options is preferred.
1. Carson AJ. J Neur Neurosurg Psychiatr. 2012;83:842-50.