Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 10  |  Issue : 3  |  Page : 300-302  

A case report of emergency cesarean section in parturient with kyphoscoliosis


1 Department of Anaesthesiology and Critical Care, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India
2 Department of Obstetrics and Gynaecology, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India

Date of Web Publication19-May-2017

Correspondence Address:
Raghavendra Vagyannavar
Room No. 336, New P.G. Hostel, SGPGIMS Campus, Rae Bareli Road, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.206573

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  Abstract 

Anesthesia for emergency cesarean section for the pregnancy with kyphoscoliosis is associated with potential risks for both mother and fetus due to alterations in maternal physiology and the pathological changes seen in kyphoscoliosis. The anesthetic management must include the well-being of both mother and fetus. The need of anesthesia for delivery in pregnant women with kyphoscoliosis is more than the normal parturient. We report the case of a 23-year-old female, full-term primigravida with kyphoscoliosis who was posted for emergency caesarean section. The anesthetic management of this patient is presented here.

Keywords: Cesarean section, general anesthesia, kyphoscoliosis, pregnancy


How to cite this article:
Vagyannavar R, Devi R. A case report of emergency cesarean section in parturient with kyphoscoliosis. Med J DY Patil Univ 2017;10:300-2

How to cite this URL:
Vagyannavar R, Devi R. A case report of emergency cesarean section in parturient with kyphoscoliosis. Med J DY Patil Univ [serial online] 2017 [cited 2020 Sep 23];10:300-2. Available from: http://www.mjdrdypu.org/text.asp?2017/10/3/300/206573


  Introduction Top


Kyphoscoliosis involves kyphosis that means anteroposterior (AP) spinal angulations and scoliosis, which is lateral spinal curvature. Scoliosis is associated with restrictive lung disease and hypoxemia, which can lead to cardiovascular compromise. If untreated, severe idiopathic scoliosis is fatal by the fifth decade as a result of pulmonary hypertension and respiratory failure.[1] Pregnancy may exacerbate the severity of spinal curvature in women with uncorrected scoliosis. Severe scoliosis is rare in parturients, which varies from 1 in 1500 to 1 in 12,000 pregnancies.[2]


  Case Report Top


A 27-year-old, 38 weeks pregnant woman with height of 130 cm and weight of 51 kg diagnosed case of cephalopelvic disproportion with fetal distress was posted for emergency cesarean section. Airway assessment revealed a Mallampatti Grade II, with intact dentition, adequate mouth opening, temporomandibular joint normal, and a full range of neck movements. Examination of the spine revealed a lateral curvature along with thoracic kyphosis. Her blood investigations were within normal limits. She had a history of recurrent respiratory tract infection. Previous records were unavailable. Chest X-ray was not there. The thorax was asymmetric with dorsolumbar kyphoscoliosis. She took last meal 8 h ago.

Her baseline vitals show pulse rate of 98 beats/min, regular, blood pressure (BP) 110/80 mmHg, and SpO2 99%. Bilateral normal vesicular breath sounds were heard on chest examination and other systems were normal. Continuous electrocardiogram, noninvasive BP, and pulse oximetry monitoring were established. We planned to proceed with general anesthesia because her short stature and risks of high spinal anesthesia. Difficult airway cart was kept ready. After preoxygenated with 100% O2 for 3 min, induction was done with intravenous (IV) injection of propofol 2.5 mg/kg until loss of response to verbal command. Succinylcholine 2 mg/kg IV was given to facilitate the endotracheal intubation. Her lower limbs were elevated by the help of female attenders so when her head comes parallel to operation table then direct laryngoscopy done with Millers Blade No. 3. CLG 2 noted, intubated with 7.5 PVC endotracheal tube after checking bilateral equal air entry tube was fixed with adhesive tape. Four pillows are kept below head for facilitation of surgery [Figure 1] and [Figure 2]. Anesthesia was maintained with 66:33 (N2O:O2) and intermittent propofol. Muscle relaxation was maintained with vecuronium 0.05 mg/kg initially followed by supplementary doses 0.01 mg/kg as and when required. Classical skin incision was given for caesarean section. A live male infant 1.8 kg with an APGAR of 8/9 was delivered. After completion of surgery, residual paralysis was reversed with neostigmine (0.05 mg/kg) and glycopyrrolate (0.01 mg/kg). Surgery lasted for 2.5 h. After surgery, she was monitored closely for 12 h in the postoperative room [Figure 3]. Postoperative period was uneventful.
Figure 1: Position of patient after intubation

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Figure 2: Intraoperative period

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Figure 3: Postoperative period

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  Discussion Top


An important focus in obstetric surgery is the safe and skilled anesthetic management to minimize risk to mother and fetus. The physiological changes in pregnancy can worse the respiratory function in a scoliosis patient with restrictive lung disorder. The maternal mortality and morbidity correlates well with the degree of functional impairment before pregnancy.[3],[4] Increased mucosal vascularity of the respiratory tract during pregnancy may lead to difficulty in endotracheal intubation. Edema of the airway results in increased potential for bleeding and smaller sized endotracheal tubes should be used for general anesthesia.[5] Patients with scoliosis suffer from restrictive lung disease which involves decreased vital capacity, functional residual capacity, tidal volume, and increased respiratory rate.[1],[6] The severity of pulmonary impairment depends on the degree of the Cobb's angle, the number of vertebrae involved, and the cephalic location of the curvature. In severe cases, displacement with rotation of the trachea and in stem bronchi may also be noted, which could cause problems during intubation for general anesthesia.[1] The severity of scoliosis depends primarily on the type, duration of scoliosis as well as on the Cobb's angle of curvature.[1],[6],[7] Thoracic scoliosis causes a significant reduction in the number of alveoli predisposing these patients to impairment in gas exchange and pulmonary hypertension.[1] The Cobb's angle is a radiological measurement made on an AP view X-ray of the spine to evaluate the severity of scoliosis. The Cobb's angle can be correlated with the pulmonary function tests. An angle more than 60° results in a restrictive type of pulmonary impairment with a decrease in forced expiratory volume in 1 s, forced vital capacity, and chest wall compliance.[1],[6] General anesthesia is indicated in scoliosis because of maternal preference when there is maternal cardiopulmonary disease and when there is difficulty in performing regional block. Severe scoliosis is associated with altered anatomy of the airway causing difficulty in laryngoscopy and intubation. It is also associated with pulmonary hypertension and patients run the risk of increase in pulmonary artery pressures during laryngoscopy and difficult intubation. Care should be taken to avoid hypoxia, hypercapnia, acidosis, and anesthetic gases such as nitrous oxide as they increase the pulmonary vascular resistance.[5] Neuraxial blockade in our patient has complications such as unpredictable block, risk of high spinal anesthesia, and failure rates. The increased intraabdominal pressure in pregnancy and the presence of engorged veins in the epidural space cause a decrease in the subarachnoid space. In such cases, the normal dose of the local anesthetic can lead to higher levels of block leading to hypotension. This is more so in cases of severe scoliosis, which can be associated with decreased volumes of cerebrospinal fluid.[8] There are reports of anesthetic management of the kyphoscoliotic parturient using a combined spinal epidural,[3] continuous spinal anesthesia,[9] and local infiltration anesthesia when there is a failure in spinal or epidural anesthesia.[7]


  Conclusion Top


The etiology of scoliosis may be varied. Based on the clinical assessment and pulmonary function tests, risk of high spinal anesthesia, and failure rates of regional techniques, administration of general anesthesia is the best option for these patients.

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.

 
  References Top

1.
Kulkarni AH, Ambareesha M. Scoliosis and anesthetic considerations. Indian J Anaesth 2007;51:486-95.  Back to cited text no. 1
  [Full text]  
2.
Hung CT, Pelosi M, Langer A, Harrigan JT. Blood gas measurements in the kyphoscoliotic gravida and her fetus: Report of a case. Am J Obstet Gynecol 1975;121:287-9.  Back to cited text no. 2
[PUBMED]    
3.
Yeo ST, French R. Combined spinal-epidural in the obstetric patient with Harrington rods assisted by ultrasonography. Br J Anaesth 1999;83:670-2.  Back to cited text no. 3
[PUBMED]    
4.
Crosby ET, Halpern SH. Obstetric epidural anaesthesia in patients with Harrington instrumentation. Can J Anaesth 1989;36:693-6.  Back to cited text no. 4
    
5.
Goodman S. Anesthesia for nonobstetric surgery in the pregnant patient. Semin Perinatol 2002;26:136-45.  Back to cited text no. 5
[PUBMED]    
6.
Gupta S, Singariya G. Kyphoscoliosis and pregnancy – A case report. Indian J Anaesth 2004;48:215-20.  Back to cited text no. 6
  [Full text]  
7.
Bansal N, Gupta S. Anaesthetic management of a parturient with severe kyphoscoliosis. Kathmandu Univ Med J (KUMJ) 2008;6:379-82.  Back to cited text no. 7
    
8.
Kardash K, King BW, Datta S. Spinal anaesthesia for caesarean section after Harrington instrumentation. Can J Anaesth 1993;40:667-9.  Back to cited text no. 8
    
9.
Moran DH, Johnson MD. Continuous spinal anesthesia with combined hyperbaric and isobaric bupivacaine in a patient with scoliosis. Anesth Analg 1990;70:445-7.  Back to cited text no. 9
    


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