key: cord-0978733-lymd2yml
authors: Runciman, N.; Tan, K.
title: P.184 Anaesthetic management of COVID-19 and malignant hyperthermia for emergency caesarean section
date: 2022-05-31
journal: International Journal of Obstetric Anesthesia
DOI: 10.1016/j.ijoa.2022.103480
sha: 441af51710e9adeebc543e8c61354e12ff02d0dd
doc_id: 978733
cord_uid: lymd2yml

nan

P.183 Parafalcine subdural haemorrhage after accidental dural puncture; a reminder to consider alternative differentials for post dural puncture headaches

Whipps Cross University Hospital, London, UK Introduction: Intracranial haemorrhage (ICH) post dural puncture is a rare complication of epidural insertion. We present a case of a 34-yearold woman who presented after a dural puncture with a severe headache. Case Report: A nulliparous woman had an inadvertent dural tap after epidural insertion with an 18G Tuohy needle. The intrathecal catheter was left in situ receiving anaesthetist-only top-ups. Following vaginal delivery, the patient was discharged with safety advice. She presented 48 h later with severe headache radiating to the frontal region, nausea and vomiting and associated neck stiffness. She had no postural aspect to the headache or photophobia. On examination she had no abnormal neurology with normal observations and blood results. A CT brain scan was requested due lack of postural component to her headache and the presenting complaint of vomiting which showed 'small parafalcine subdural haemorrhages (SDH) on the right side of the inter hemisphere space'. Neurosurgical advice was to be admitted for conservative management and observation. Further imaging including CT Venogram and CT Angiogram did not show any vascular abnormality. The patient's symptoms improved and she was discharged. Discussion: Care should be taken to rule out other more serious causes of headaches in postnatal women such as meningitis, cerebral vein thrombosis, preeclampsia and ICH [1] . The pathophysiology behind SDH after dural puncture is thought to be from traction and rupture of bridging veins due to low CSF pressure and vasodilation [1] . This patient had no neurological deficit and her symptoms resolved but other case reports include large SDH after epidural insertion needing neurosurgical intervention [1] . Although SDH after dural puncture is rare, a high level of suspicion will facilitate earlier detection. Symptoms described are headache, vomiting, altered mental state, focal motor deficit, visual changes and aphasia/dysarthria [2] . When symptoms are atypical of post-dural puncture headache (PDPH) or do not respond to usual measures, investigations such as non-contrast CT should be performed and depending on level of suspicion CT angiogram and venogram to investigate for vascular abnormalities and venous sinus thrombosis. In patients who are anticoagulated earlier imaging is encouraged. Timely discussion with neurology and neurosurgeons is of paramount importance. This rare case report highlights the importance of early neurological imaging to investigate PDPH.

hyperthermia for emergency caesarean section N. Runciman, K. Tan Ayrshire Maternity Unit, Crosshouse, UK Introduction: We present a case of complex decision making about anaesthetic management in a woman with malignant hyperthermia, COVID-19, anxiety, obesity and fetal distress. Pregnant women with COVID-19 are more likely to be delivered by caesarean section (CS). The decision making in the management of these patients is complex and requires a multidisciplinary team approach to ensure the safety of the patient and delivery of fetus. Case Report: A 37-year-old woman, 39 + 4 weeks gestation, G2P1, previous CS, presented to maternity assessment unit with uterine contractions, in established labour. She was unvaccinated and had tested positive for COVID-19 five days earlier, and an elective CS had been planned for 10 days after her positive PCR test. She had a past medical history of hypothyroidism, biopsy proven malignant hyperthermia (MH), anxiety and obesity body mass index 43 kg/m 2 (38 at booking). At presentation her cardiotocography was abnormal requiring urgent delivery, by category 2 CS. She was tachypnoeic and tachycardic but oxygen saturations were 100% on air. There were no recent blood results available. A successful single-shot spinal anaesthetic was performed and her baby was delivered in good condition and the operation was uncomplicated. She was discharged home day 2 post CS, but deteriorated day 10 of her COVID-19 illness with worsening hypoxia secondary to COVID-19 pneumonitis. She was admitted to ICU for invasive ventilation and proning. Unfortunately she was not deemed a candidate for extracorporeal membrane oxygenation (ECMO), and after a superimposed bacterial infection, deteriorated precipitously and passed away after three weeks in ICU. Discussion: We carried out regional anaesthesia in this patient after risk-benefit analysis. Despite the potential risks of thrombocytopenia and disseminated intravascular coagulopathy with COVID-19, we felt the benefits of spinal anaesthesia in a patient with malignant hyperthermia, fetal compromise and potential postoperative respiratory decompensation outweighed these risks [1] . Prior handover from the high-risk clinic enabled preparation for total intravenous anaesthesia at short notice. She tolerated the spinal anaesthetic well and was able to spend time with her baby immediately after. This case is important as the management of patients for operative delivery with COVID-19 is becoming more important with increasing prevalence and low number of pregnant patients vaccinated. Introduction: Thrombocytopenia occurs in one-third of patients with COVID-19 infection compared with 7-12% of non-COVID pregnant patients [1] . We describe the anaesthetic management of a patient with COVID-19 undergoing an elective caesarean section presented with moderate thrombocytopenia. Case Report: A 28-year-old nulliparous woman at 39 + 4 weeks of gestation was listed for an elective caesarean section due to breech presentation. Her past medical history included mild anxiety. At 28 weeks the platelet count was 111 × 10 9 /L and 72 × 10 9 /L at term. Preeclampsia had been excluded. Asymptomatic COVID-19 infection was incidentally discovered a week before delivery. The agreed anaesthetic plan was to request platelets to be available as they take 75 minutes to procure. Spinal anaesthetic was planned as per the current COVID-19 guidelines. There were concerns regarding the risk of epidural haematoma due to thrombocytopenia. A pool of platelets was given preoperatively as per the recommendation of the haematologist. The post-transfusion platelet count was 86 × 10 9 /L. Spinal anaesthetic was performed with a 25G Sprotte needle. Hyperbaric bupivacaine 12.5 mg with diamorphine 300 μg was used. It was an uneventful caesarean section with an estimated blood loss of 500 mL. The woman's platelet count 6 hours postoperatively was 87 × 10 9 /L and increased to 96 × 10 9 /L after 2 days. Discussion: Thrombocytopenia during pregnancy affects 5-10% of patients [2] . Aetiologies include gestational/immune thrombocytopenia, preeclampsia, and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome. Mild thrombocytopenia was recorded in a third of non-pregnant patients with COVID-19. Thrombocytopenia is frequently associated with moderate to severe coronavirus disease. Many observations show that moderate to severe thrombocytopenia can exist in asymptomatic COVID-19. Thrombocytopenia was found in 2 of 14 cases (14%) of COVID-19 patients undergoing neuraxial procedures with the lowest reported platelet count of 81 × 10 9 /L [1] . A platelet count of 70 × 10 9 /L carries a low risk for neuraxial anaesthesia, especially for those at high risk for general anaesthesia [1] . We opted for transfusion of one platelet pool preoperatively considering the borderline platelet count and the progressive course of thrombocytopenia. Appropriate monitoring of the platelet count is essential to enable safe discharge. Good communication between clinical teams and haematologist ensured a positive outcome for our patient and her baby.

Epidural anaesthesia for caesarean section for pregnant women with rheumatic heart disease and mitral stenosis

Regional anaesthesia in the patient with pre-existing neurological dysfunction

Subdural haematoma after dural puncture headache treated by epidural blood patch

Intracranial subdural haematoma after epidural anaesthesia: a case report and review of the literature

Neuraxial procedures in COVID-19 positive parturient: a review of current reports

Thrombocytopenia in pregnancy