Oh, No! Emergent Cesarean. Spinal Cord Transection. Regional Anesthesia-not an option!
Abstract Number: S3D-2
Abstract Type: Case Report/Case Series
Autonomic hyperreflexia (AH) occurs during labor in up to 90% of women with cord lesions at/above T-6.3 Noxious stimuli can trigger sympathetic discharge resulting in severe hypertension with resultant impaired vasodilation below the level of spinal cord transection. Efferent signals also cause diaphoresis and flushing. Prevention of AH in a parturient includes controlling pain and uterine irritation via regional anesthesia.1 Treatment of AH can also be achieved with anti-hypertensives, regional anesthesia, analgesics, and magnesium.2
A 31-year-old primigravid female at 36 weeks 4 days with history of spastic paraplegia secondary to traumatic spinal cord transection at T6, and also inferior vena cava thrombosis on therapeutic enoxaparin (80 mg daily) presented to the emergency room. She had complaints of mild abdominal discomfort, sweatiness, and headache. Her pregnancy was complicated by a fall out of her wheelchair requiring cervical fusion. Her pre-operative clinic plan was induction of labor at 39 weeks with epidural anesthesia; however, due to breech position and risk of version, she was later scheduled for a cesarean section (c/s) at 40 weeks. At admission, she was in active labor with normal blood pressure (BP). She had eaten 1 hour prior and her last dose of enoxaparin was 14 hours prior. The patient reported worsening headache, diaphoresis, and flushing; so the team proceeded with emergent c/s under general anesthesia. Rapid sequence induction (RSI) and C MAC™ were used. The case proceeded with maximum BP 146/95 at uterine incision, which decreased to presentation levels with administration of hydromorphone. There was no bradycardia or complication during the case. Postoperatively, a lumbar epidural was placed to prevent recurrence of AH. A heparin infusion was started for anticoagulation and stopped 6 hours prior to removal of epidural on POD1.
In a parturient with spinal cord injury at or above T6, there is significant risk for AH during labor. The consensus for AH risk reduction is regional anesthesia at the start of labor; however, this patient was on therapeutic anticoagulation. While preparing to proceed with c/s, some symptoms of AH developed requiring emergent c/s under general anesthesia. With concern for full stomach and limited neck mobility, RSI and video laryngoscopy were used. Opioids were given to decrease sympathetic response to pain, and a lumbar epidural was placed post-operatively to reduce further risk of AH.
1. Krassioukov A, W. D. (2009). A Systematic Review of the Management of Autonomic Dysreflexia After SCI. Arch Phys Med Rehab , 90, 682-95.
2. Maehama T, I. H. (2000). Management of AH with magnesium sulfate during labor in a woman with spinal cord injury. Am J Ob Gyn (26), 409-11.
3. Schonwald G, F. K. (1981). Cardiovascular complications during anesthesia in chronic spinal cord injured patients. Anesthesiology (55), 550-58.