MAMC Journal of Medical Sciences

CASE REPORT
Year
: 2018  |  Volume : 4  |  Issue : 3  |  Page : 145--148

Emergency Cesarean Delivery in a Parturient With Intracranial Tumor: Anesthesiologist’s Challenge


Kapil Chaudhary1, Sandeep Mehra2, Kirti N Saxena1, Bharti Wadhwa1, Himanshu Sikri3,  
1 Maulana Azad Medical College and Associated Hospitals, New Delhi, India
2 Venkateshwar Hospital, Dr RML Hospital, New Delhi, India
3 Department of Anaesthesia, Dr RML Hospital, New Delhi, India

Correspondence Address:
Dr. Kapil Chaudhary
Department of Anesthesia and Intensive Care, Maulana Azad Medical College and Associated Lok Nayak Hospital, 22/24, West Patel Nagar, New Delhi-8
India

Abstract

Anesthetic management of a patient having an intracranial tumor undergoing cesarean section is challenging because of a combination of factors including their diagnosis, physiological changes of pregnancy, fetal viability concerns and complexity of surgical and anesthetic interventions. The scenario is more challenging in emergency surgery as the time for optimization and multidisciplinary involvement is minimal. We discuss successful management of a term primigravida with intracranial tumor who presented for emergency cesarean delivery. The anesthetic challenges and the management options are discussed.



How to cite this article:
Chaudhary K, Mehra S, Saxena KN, Wadhwa B, Sikri H. Emergency Cesarean Delivery in a Parturient With Intracranial Tumor: Anesthesiologist’s Challenge.MAMC J Med Sci 2018;4:145-148


How to cite this URL:
Chaudhary K, Mehra S, Saxena KN, Wadhwa B, Sikri H. Emergency Cesarean Delivery in a Parturient With Intracranial Tumor: Anesthesiologist’s Challenge. MAMC J Med Sci [serial online] 2018 [cited 2019 Sep 15 ];4:145-148
Available from: http://www.mamcjms.in/text.asp?2018/4/3/145/249027


Full Text



 Introduction



Intracranial tumors are rarely associated with pregnancy.[1] The anesthetic management of a patient having an intracranial tumor undergoing caesarean section poses a challenge to the anesthesiologist with conflicting anaesthetic considerations of neuro- and obstetric anesthesia;[2],[3] and little evidence/guidelines to guide the decision making.[2],[4],[5] The management of a parturient having an intracranial tumor presenting for emergency cesarean section becomes more challenging as the time for optimization and multidisciplinary involvement is minimal.[4],[5]

 Case Report



A 32 yr old, 60 kg, primigravida with 37 weeks gestation was referred to our hospital with the complaints of an episode of severe headache with nausea followed by seizure 2 days back. However, she was fully conscious on admission. Magnetic resonance imaging of the brain revealed an extra-axial dural-based lesion measuring 2.5 × 3.5 × 4.5 cm in left frontal region with peri-lesional edema and mass effect suggestive of meningioma [[Figure 1]]. The treatment was started with tablets levetiracetam 500 mg, dexamethasone 2 mg, and syrup glycerol as per the advice of neurosurgeon. All the baseline investigations were normal. An elective cesarean section was planned at 38 weeks of pregnancy in consultation with neurosurgeon in view of an intracranial mass.{Figure 1}

However, the patient started leaking per vaginum on the third day of admission and went into active labor within 4 h and an emergency cesarean delivery was planned. The glasgow coma scale (GCS) on examination was 15 with no other detectable anomaly. Two large bore (16G) intravenous (IV) canulae were secured; premedication with ranitidine 50 mg IV and metoclopramide 10 mg IV were administered; and supine-wedged position maintained. General anesthesia (GA) with modified rapid sequence intubation was administered using IV thiopentone 250 mg and rocuronium 72 mg. Lignocaine hydrochloride 90 mg IV was administered 90 s prior to intubation followed by quick laryngoscopy (10 s) and tracheal intubation with a cuffed orotracheal tube #6.5.

Intraoperative period was uneventful with stable vital parameters. Blood loss was about 450 ml which was replaced with 6% hydroxyl ethyl starch. End tidal carbon di oxide was maintained around 32 to 34 mmHg, arterial oxygen saturation maintained more than 97%, and normothermia was ensured. Anesthesia was maintained with 1.8% sevoflurane in 100% O2 before delivery. Fentanyl 120 μg IV and 10-IU oxytocin IV (slowly over 30 min) were administered after delivery of baby and the sevoflurane concentration was reduced to 1.4%. The baby was delivered in about 8 min with APGAR scores 9 and 9 at first and fifth minutes, respectively, after delivery.

On completion of surgery, after adequate reversal of neuromuscular blockade and administration of lidocaine; awake extubation was performed and patient was transferred to the postoperative care unit. Postoperative GCS was 15, and there was no neurological deterioration. Transverse abdominis plane block was administered for postoperative pain relief. Paracetamol 1 g IV 6 hourly was administered in the postoperative care unit. The further hospital course was uneventful, and the patient was advised to follow-up in the neurosurgery department. The patient underwent tumor excision after 1 month and was discharged on antiepileptic medications. Both the mother and child were fine at the time of writing of manuscript. Written informed consent was taken for publication of the data.

 Discussion



The anesthetic management of parturient with intracranial tumor presenting for emergency cesarean delivery is challenging. It demands preoperative patient optimization, multidisciplinary involvement, and appropriate anesthetic plan formulation in a short span of time. In the absence of any preformed guidelines for management of such patients,[4],[5] the anesthetic plan should be guided by the firm principle of nihil nocere (do not do anything that can cause harm)[6] and ensure safety of both the mother and fetus per operatively.[7]

GA using modified rapid sequence intubation with a cuffed endotracheal tube and controlled ventilation was administered to the present patient. Although spinal anesthesia is the preferred technique for cesarean delivery, it carries a high risk of lumbar puncture–induced herniation and the risk of hypotension both of which could reduce cerebral perfusion and be deleterious.[7] Epidural anesthesia could have been an alternative; however, it is slow in onset, technically difficult, and carries a high risk of accidental dural puncture (which can lead to acute neurological deterioration and even death in such patients), and an increase in intracranial pressure (ICP) by cerebrospinal fluid (CSF) shift to the brain (from epidural injection volume)[7] in an actively laboring parturient with an intracranial mass.

When administering GA to a parturient with an intracranial lesion; consideration should be given to the conflicting clinical considerations of neuro and obstetric anesthesia.[3] Although rapid sequence intubation is mandatory in obstetric anesthesia, it may be limited to patients with GCS < 8/15 in neuroanaesthetic care. Use of low doses of thiopentone in contrast to high doses to decrease ICP; preference of succinylcholine in contrast to its avoidance to prevent an increase in ICP; and avoidance of hyperventilation to prevent fetal adverse effects in contrast to its preference to reduce ICP are some of the conflicting considerations of obstetric anesthesia and neuroanesthesia respectively.[3] In addition, opioids are administered at the time of induction in neuroanesthesia to prevent/ blunt the response to laryngoscopy and intubation and an increase in ICP, while they are administered only after delivery of baby in obstetric anesthesia.[3] Pre-oxygenation, aspiration prophylaxis, and avoidance of aorto-caval compression are the requirements of a cesarean section. Avoidance of hypoxia, hypercarbia, acidosis, hypothermia and maintenance of hemodynamic stability are important for maintaining both uteroplacental perfusion and cerebral perfusion pressure (CPP) . In addition, vigilant monitoring and adequate analgesia are the common requirements.[3]

Drug administration should be based on their effect on the fetus and ICP. All the drugs administered to the present patient belonged to Food and Drug Administration pregnancy category B or C. Thiopentone sodium and rocuronium were administered, whereas propofol and succinylcholine were avoided. Thiopentone decreases ICP and maintains CPP, whereas propofol decreases CPP. Succinylcholine raises ICP, whereas rocuronium in a dose of 1.2 mg/kg provides equally optimal intubating conditions in 60 s without any significant elevation in ICP.[7] Fentanyl was administered after the delivery of baby because of its potential to cross the placental barrier and produce profound neonatal respiratory depression.[7] Nitrous oxide can worsen cerebral vasodilation when used with a potent inhalation agent.[8] Deeper planes of anesthesia maintained with 1.8% sevoflurane pre-delivery and with 1.4% sevoflurane and fentanyl post-delivery helped in completely avoiding nitrous oxide. Administration of 100% oxygen initially during preoxygenation and later after intubation also helped achieve high APGAR scores. Oxytocin is safe in patients with intracranial tumor without any adverse effects,[4] whereas ergotamine may cause increased ICP and was avoided.[4]

The prevention of increase in ICP and maintenance of CPP was important as the intracranial mass removal was planned in a later setting. It was achieved by judicious use of drugs as above, preventing stress response to intubation and extubation (use of lidocaine and gentle, quick laryngoscopy), maintenance of hemodynamic stability, maintaining adequate depth of anesthesia and analgesia (peroperative multimodal analgesic approach). Our anesthetic technique did not cause any fetal/maternal morbidity/mortality. The patient could be extubated in the operative room with GCS 15, and peroperative course was uneventful.

The case is unique as there is no reported literature of emergency cesarean delivery in a patient with intracranial tumor without tumor removal. Previous reports relate to either emergency neurosurgical management of tumor with[8] or without cesarean delivery in the same sitting during pregnancy[1],[9] or of emergency cesarean delivery and removal of intracranial tumor in the same sitting.[3],[10]

GA with thiopentone, rocuronium, fentanyl, and titrated dose of sevoflurane proved to be safe in our parturient with intracranial tumor presenting for emergency cesarean delivery. Quick and appropriate decision-making with interdisciplinary involvement, maintenance of hemodynamic stability, and control of ICP are the major goals.

Acknowledgments

We would like to thank the senior residents, postgraduates, and technical staff of the Departments of Anesthesia and Obstetrics, Lok Nayak Hospital, who helped in the smooth conduct and postoperative care of this patient. In addition, a special thanks to the Neurosurgery Department of GB Pant Hospital for their valuable peroperative advice and postoperative surgical management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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