CASE REPORT Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 164-166

Neuraxial anaesthesia in a parturient with space occupying lesion in brain for caesarean section: Demystifying the myth – A case report with review

Abinaya Ramachandran, Sivakumar Segaran, Nikithamani, RV Ranjan
Department of Anesthesia and Critical Care, Pondicherry Institute of Medical Sciences, Pondicherry, India

Date of Submission09-Oct-2021Date of Acceptance15-Nov-2021Date of Web Publication02-Sep-2022

Correspondence Address:
Dr. Abinaya Ramachandran
Department of Anaesthesia and Critical Care, Pondicherry Institute of Medical Sciences, Pondicherry
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/JOACC.JOACC_94_21

Pregnancy makes a patient undergo diverse physiological changes and predisposes them to many pathological disorders such as pre-eclampsia, eclampsia, cortical vein thrombosis, and pituitary apoplexy. Any intervention during pregnancy presents a unique challenge as it affects two individuals. Once diagnosed with a clinical condition, they are prone to further medical, obstetric and anaesthetic complications. Herein, we report the anaesthetic management of a 32-year-old female previously diagnosed with pituitary adenoma and now presenting with twin pregnancy for emergency caesarean section along with emphasis on the anaesthetic concerns pertinent to brain tumours in pregnancy.

Keywords: Brain tumours, neuraxial anaesthesia, pituitary adenoma, pregnancy

How to cite this article:
Ramachandran A, Segaran S, Nikithamani, Ranjan R V. Neuraxial anaesthesia in a parturient with space occupying lesion in brain for caesarean section: Demystifying the myth – A case report with review. J Obstet Anaesth Crit Care 2022;12:164-6
How to cite this URL:
Ramachandran A, Segaran S, Nikithamani, Ranjan R V. Neuraxial anaesthesia in a parturient with space occupying lesion in brain for caesarean section: Demystifying the myth – A case report with review. J Obstet Anaesth Crit Care [serial online] 2022 [cited 2022 Sep 3];12:164-6. Available from: https://www.joacc.com/text.asp?2022/12/2/164/355357   Introduction 

The incidence of brain tumours in pregnancy ranges from 2.0 to 3.2 per 100,000 women.[1] It can either be a primary tumour or metastasis from elsewhere. The common primaries include meningiomas, gliomas, schwannomas, pituitary adenomas and pineal gland tumours.[2] Hormonal changes, increase in growth factors and angiogenic factors during pregnancy increase the size of hormone-responsive tumours or can unmask a previously undiagnosed tumour.[3] Thus, there is a rise in intracranial pressure (ICP), cerebral oedema, headache, nausea, vomiting, visual field defects and worsening of neurological status, which are often misinterpreted as hypertensive disorders of pregnancy. MRI is the diagnostic modality of choice, but sometimes, we might have to go for computed tomography (CT) with shielding of the abdomen. The primary obstetric management depends upon the gestational age and the neurological status of the patient. The decision to undergo a vaginal or caesarean delivery depends upon many clinical factors. At present, there is no specific consensus available for the anaesthetic management for a parturient with brain tumour except for a few case reports and clinical communications.

  Case Report 

A 32-year-old primi gravida at a gestational age of 38 weeks and 2 days with dichorionic diamniotic twin gestation was admitted in our obstetrics department for safe confinement of pregnancy. She had no complaints at the time of admission. The patient had taken ovulation induction drugs for conception. The patient was previously diagnosed to have pituitary adenoma 2 years ago with serum prolactin level of 315.2 ng/ml and was started on oral cabergoline 0.5 mg 6 days a week for 1 year. She was also on treatment with oral levothyroxine 75 μg OD for hypothyroidism since conception. The thyroid profile of the patient showed free T3:2.8 pg/ml, free T4:1.3 ng/dl and TSH: 6.8 uIU/ml. The patient was obese with a BMI of 38 kg/m2, had a short neck with double chin and Mallampati grade III. The patient had MRI at 9 months of gestation which showed that the tumour location was not in the midline or obstructing the ventricles. There was no midline shift or signs of increased ICP. Ophthalmology and neurosurgical consultation was obtained to look for visual field defects and any increase in size of the tumour at 36 weeks. Patient had to be taken up for emergency caesarean section (category 3) in view of non-progression of labour. After obtaining informed written consent, the patient was shifted to the operating room in left lateral position. Under strict aseptic precautions, an 18-G Tuohy's needle was inserted at L2-L3 intervertebral space; the epidural space was identified using the loss of resistance technique at a depth of 4 cm. The catheter was inserted and fixed at 9 cm from skin level. We preferred higher space to decrease the volume of local anaesthetic to achieve T4 blockade. Surgical anaesthesia was achieved using 12 ml of 0.5% hyperbaric bupivacaine given as 5 ml aliquots to reach T4 dermatome after which the surgeon proceeded with caesarean section. After the delivery of the babies, intravenous oxytocin 10 U was given as an infusion. After securing haemostasis, the uterus was sutured in two layers and the abdomen was closed in layers. The patient was shifted to a high-dependency unit to monitor change in neurological status or any other sequelae. Epidural catheter was removed at the end of surgery after giving 20 μg of fentanyl diluted in 2 ml of saline. The postoperative period was uneventful with minimal pain which was managed with diclofenac sodium 100 mg suppository at the end of the procedure and intravenous paracetamol 1 gm was used 8th hourly. The mother and both the babies were discharged on fifth postoperative day without any complications.

  Discussion 

The incidence of brain tumour during pregnancy is relatively less common when compared to non-pregnant women.[4] Hormone-sensitive tumours undergo enlargement during pregnancy. Some patients with brain tumours die during labour, few undergo remission in the immediate postpartum period, and few undergo relapses as well. Thus, management of these patients for labour and caesarean delivery requires extensive knowledge of the intracranial physiology with compensatory auto-regulatory mechanisms.

Our patient had a pituitary adenoma without any mass effect and obstruction to the CSF flow. As it was an emergency surgery with inadequate nil per oral status and difficult airway, we chose regional anaesthesia over general anaesthesia. After informed consent, we chose epidural over spinal because of the inability to extend the duration of anaesthesia with spinal anaesthesia if the duration of surgery extends. Even the large volume of local anaesthetic needed to provide surgical anaesthesia can increase the ICP due to translocation of CSF from intraspinal to intracranial compartment.[5] Thus, it was given in a graded manner so that the magnitude of increase can be decreased and usually it is transient.

There are many myths and controversies with regard to administration of neuraxial block to a parturient with intracranial space-occupying lesion (ICSOL). Any space-occupying lesion in the cranium is considered as a contraindication for neuraxial anaesthesia fearing the risk of brain herniation. There are no randomized controlled trials available in the literature supporting effectiveness of one anaesthesia technique over the other. As with all published case reports, there is an inherent bias in the cases that are chosen for reporting.

The possibilities of the patient having signs of raised intracranial tension, obstruction to the cerebrospinal fluid flow, cranial nerve palsies, difficult airway, significant cardiac or hypertensive disorders, ability to tolerate the stress response due to laryngoscopy and intubation should be considered before choosing any anaesthesia technique.

General anaesthesia with endotracheal intubation is usually the standard practice when there is ICSOL for better control of ventilation and haemodynamics.[6],[7] Sushma et al.[8] successfully provided general anaesthesia in a parturient with pituitary adenoma for caesarean section. Semple et al.[9] favours doing an epidural anaesthetic for caesarean delivery if there are equally or more compelling risks associated with a general anaesthetic.

Neuraxial anaesthesia is also a viable option in such patients but only after careful assessment of the intracranial compliance (decompensated or normal) and the tumour location (if it is in the midline obstructing the flow of CSF/compressing the ventricles).[10],[11] After a dural puncture, the CSF leak causes a pressure gradient between the intracranial and intraspinal compartment. If there is an obstruction to the flow, the CSF cannot translocate from the intracranial to the intraspinal compartment, leading to brain tissue herniation. The risk of dural puncture with epidural anaesthesia cannot be neglected even in experienced hands. It can be minimized with ultrasound use by measuring the distance from skin to epidural space preoperatively and taking utmost care by advancing the needle in small steps.[12] However, we did not use ultrasound to measure the depth of epidural space as it was an emergency caesarean section.

Therefore, the choice of anaesthesia for each case must be tailored after a comprehensive evaluation after weighing the risks over the probable benefits.

  Conclusion 

We describe the successful use of neuraxial anaesthesia in an obese parturient with twin gestation and an intracranial tumour without any signs of raised ICP and obstruction to CSF drainage. However, it has to be decided based on the individual's clinical status, anaesthesiologist's expertise in managing cases under regional anaesthesia along with the patient's desirability to undergo surgery awake.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

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