Spinal anesthesia for Cesarean section in a parturient with long QT syndrome

PURPOSE: To report the first use of spinal anesthesia for Cesarean section (CS) in a parturient with a long QT syndrome (LQTS) and an automatic implantable cardiac defibrillator (AICD). Although both general and epidural anesthesia have been described for CS in patients with LQTS, there are no previous case reports on the use of spinal anesthesia. The clinical features, diagnosis, treatment and anesthetic management of LQTS are discussed. CLINICAL FEATURES: A 31-yr-old woman, gravida 2 para 1 known to have LQTS and an AICD, presented in labour at 35 weeks gestation, three weeks before her scheduled CS. Her previous delivery by CS under spinal anesthesia at our institution was uneventful. On this occasion, we elected to administer spinal anesthesia because she was asymptomatic (no arrhythmia or cardiac arrest) for the last few years, was hemodynamically stable, and had received uneventful spinal anesthesia before. CONCLUSION: Spinal anesthesia was used safely for CS in this parturient with LQTS.     

Spinal anesthesia in a parturient complicated with idiopathic thrombocytopenic purpura

A 27-yr-old parturient with idiopathic thrombocytopenic purpura was scheduled to undergo resection of a left ovarian cyst at 15 weeks gestation. Platelet counts were between 46,000 and 64,000.microliter-1, bleeding time was 2 min, and she denied having unusual bleeding diathesis. As the patient was reluctant to receive general anesthesia for fear of latent adverse effects of the drugs on the fetus, we selected spinal anesthesia and the perioperative course was uneventful. However, it is questionable to perform regional anesthesia in patients with coagulation disorders, for spinal hematomas leading to paraplegia can be a rare but devastating complication of regional anesthesia. According to our extensive literature review, it was revealed that platelet insufficiency, both in terms of function and count, did not represent a major risk factor for spinal hematomas associated with regional anesthesia, especially for spinal anesthesia. We suggest that spinal anesthesia may be safely performed in patients if their platelet counts exceed around 50,000.microliter-1.     

Currarino triad: a case report

The authors report a case of Currarino triad with a combination of anterior sacral meningocele and mature teratoma, sacral body deformity, anorectal stenosis, and tethered cord. A newborn girl suffered from vomiting, abdominal distension and constipation. Initially, a diverting colostomy was performed at the age of one month. 7 months later, at the age of 8 months, we performed posterior sagittal anorectoplasty (PSARP): As a result, extirpation of teratoma, excision of meningocele, untethering of the spinal cord, and anorectoplasty were achieved simultaneously without complication. We suggest the use of an MRI to specify the presence of anosacral and spinal cord anomalies in patients with intractable constipation and we recommend combined pediatric and neurosurgical assessment and management for all cases of Currarino triad.     

Currarino triad associated with Hirschsprung's disease

The Currarino syndrome is a rare hereditary condition. The major symptom is chronic constipation from early life, and, in more than 80% of the cases, this condition is diagnosed in the first decade. The authors describe an unusual case of a complete Currarino triad associated with Hirschsprung’s disease in a 6-year-old girl, presenting persistent constipation and abdominal distension. The patient is free of symptoms after surgical treatment of anorectal malformation and Hirschsprung’s disease. The presacral mass was excised. Complete screening of the pelvis is recommended by using ultrasonography, computed tomography (CT) scan, and radiography in patients with a history of chronic constipation from early childhood.     

H-type rectovaginal fistula associated with the Currarino triad

We describe a case of H-type rectovaginal fistula associated with the Currarino triad (anorectal stenosis, sacral defect, presacral mass). Presenting symptoms included passage of feces per vaginam, signs of intestinal subocclusion without perianal inflammation, left leg paresis and foul-smelling urine. An anterior sacral meningocele was repaired at the age of three months. At age 18 months the fistula was excised through a perineal approach after creation of a protective colostomy. Diagnostic and therapeutic aspects of this malformation are discussed.     

Spinal anesthesia for a parturient with an iatrogenic skull base defect and CSF leak

A patient with an iatrogenic skull base defect and cerebrospinal fluid leak presented with rupture of amniotic membranes at 37 weeks’ gestation. She had daily rhinorrhea that began in her first trimester of pregnancy and 11 months after endoscopic sinus surgery performed for chronic sinusitis. Consultation among the otolaryngologist, obstetrician, and obstetrical anesthesiologist were completed during the patient’s second trimester to determine the most desirable type of delivery and anesthesia. A cesarean section was performed so as to avoid pushing in the second stage of labor that could worsen the cerebrospinal fluid leak. A spinal anesthetic was performed uneventfully. The patient had an unremarkable recovery from the operative delivery and spinal anesthesia. The pathophysiology, management, and anesthetic concerns of patients with cerebrospinal fluid leaks are reviewed.     

The Currarino triad: the variable expression

Background

The Currarino triad is a relatively unknown hereditary disorder linked to the 7q36 region and characterized by an anorectal malformation, sacrococcygeal defect, and a presacral mass.

Purpose

The aim of the study was to report the highly variable expression in patients with the Currarino triad and provide a guideline for the clinician if the Currarino triad is suspected.

Methods

We examined the symptoms and associated anomalies in 5 families with the Currarino triad by retrospective chart review.

Results

Fifteen patients had Currarino-associated anomalies. This included anorectal malformation in 9, a presacral mass in 9, and a sacral bone defect in 15. Tethered cord was present in 4 patients. There were 12 symptomatic patients. Constipation was diagnosed in all of them. Other symptoms included recurrent urinary tract infections caused by bladder dysfunction in 5, abnormal gait in 1, and another patient who initially presented with meningitis. Two carriers of the genetic defect had no symptoms or anomalies.

Conclusions

The phenotypical expression of the gene mutations causing the Currarino triad can vary from asymptomatic to patients presenting with the complete triad. Presence of a crescent-shaped defect of the sacral bone may be used as initial screening method. As the penetration of the genetic defect is variable, DNA screening is the only method to fully exclude the triad.     

Presacral tumor associated with the Currarino triad in an adolescent

A 17-year-old woman presented with pain over the sacral region. Plain radiographs of the sacrum demonstrated a bony deformity of the sacrococcygeal region in the shape of a scimitar. Magnetic resonance imaging showed a cystic mass of the presacral region which appeared to be continuous with the dural sac. An anteroposterior view myelogram revealed caudal elongation of the dural sac, and on the lateral view it was recognized as an anterior meningocele. At surgery, we confirmed a connection between the presacral mass and the rectum. In light of the combination of a sacral bony deformity, presacral mass including meningocele, and mass-rectum connection, we made the diagnosis of the Currarino triad, which is a rare complex of congenital caudal anomalies. The patient underwent excision of the presacral mass. Histologic examination of the resected specimen revealed features of an epidermoid cyst. Received: 4 August 1999     

Spinal anesthesia using a continuous spinal catheter for cesarean section in a parturient with prior surgical correction of scoliosis

This case report demonstrates the successful anesthetic management of cesarean section for a 29-year-old primiparous parturient with a past history of a scoliosis operation at 13 years of age. An Isola hook and screw-rod system had been implanted as posterior spinal instrumentation at the level of T3-L3. We titrated hyperbaric bupivacaine 7 mg combined with fentanyl 15 μg through a continuous spinal catheter, placed with a catheter-over-needle technique in order to avoid unintentional wide spread of anesthetic agents. The anesthetic level was T4 at the start of the operation. Her surgery was carried out without any problems. Headache, as a dural tap-related complication, was not observed. Spinal anesthesia with the titration of anesthetic agents for cesarean section is considered to be one of the choices for a parturient who has had spinal instrumentation.     

Recurrent meningitis associated with complete Currarino triad in an adult--case report

A 58-year-old woman presented with Currarino triad manifesting as recurrent meningitis. Currarino triad is a combination of a presacral mass, a congenital sacral bony abnormality, and an anorectal malformation, which is caused by dorsal-ventral patterning defects during embryonic development. She had a history of treatment for anal stenosis in her childhood. Radiographic examinations demonstrated the characteristic findings of Currarino triad and a complicated mass lesion. The diagnosis was recurrent meningitis related to the anterior sacral meningocele. Neck ligation of the meningocele was performed via a posterior transsacral approach after treatment with antibiotics. At surgery, an epidermoid cyst was observed inside the meningocele. The cyst content was aspirated. She suffered no further episodes of meningitis. The meningitis was probably part of the clinical course of Currarino triad. Radiography of the sacrum and magnetic resonance imaging are recommended for patients with meningitis of unknown origin. The early diagnosis and treatment of this condition are important.     

Hereditary sacral agenesis with presacral mass and anorectal stenosis: the Currarino triad

A family with autosomal dominant inheritance of sacral agenesis is described. Ten members were affected; four had associated presacral teratomas and anterior sacral meningoceles, giving rise to serious complications in three, including bacterial meningitis, local recurrence of teratoma and perianal sepsis. Three of those with presacral masses presented initially with anorectal anomalies. Other associated abnormalities included tethering of the cord, hydrocephalus, duplex ureter, hydronephrosis, vesicoureteric reflux, neurogenic bladder, bicornuate uterus, rectovaginal fistula and hereditary spherocytosis. Early diagnosis and surgical excision of a presacral mass is advised to prevent future morbidity and mortality.     

Spinal anesthesia performed for cesarean delivery after external ventricular drain placement in a parturient with symptomatology from an intracranial mass

We describe a case in which spinal anesthesia was undertaken in a pregnant patient with a space-occupying tumor and significant symptomatology. The collaborative efforts of all medical disciplines involved and the willingness of the neurosurgeon to discuss and help determine the safety of neuraxial anesthesia, culminated in placing an external ventricular drain to help monitor and manage intracranial pressure, so that we could proceed with spinal anesthesia and more easily monitor neurologic status.     

Obstetrical anesthesia for parturient patients with HELLP syndrome

In the period from April 1995 to March 2000, 11 parturient patients were diagnosed as having HELLP syndrome and underwent Caesarian section at our institution. All of the patients also had eclampsia or preeclampsia. Six of the operations were performed under general anesthesia and 5 were performed under regional anesthesia (one epidural and 4 spinal blocks). Subarachnoid anesthesia was well tolerated and clinically serious decreases in blood pressure with onset of block were not common. In the cases in which general anesthesia was used, control of blood pressure was difficult and the Apgar scores of the babies were low. No major complications occurred during the postoperative periods. Anesthetic management of a parturient patient with HELLP syndrome is modeled on the underlying preeclamptic condition. Determination of the appropriate anesthetic should be based on the patient's condition, condition of the fetus, and the urgency of the situation.     

Obstetrical anesthesia for a parturient with a ventriculoperitoneal shunt and third ventriculostomy

PURPOSE: To describe the anesthetic considerations for a primiparous woman whose history included four neurosurgeries: ventriculoperitoneal (VP) shunt insertion, evacuation of a subdural hematoma, shunt revision, and third ventriculostomy for hydrocephalus secondary to aqueductal stenosis. CLINICAL FEATURES: A 37-yr-old GI, P0 woman with a VP shunt and third ventriculostomy was assessed in the Obstetrical Anesthesia Clinic at 36 wk. gestation to consider analgesic options for labour and delivery and review anesthetic management in the event that an operative delivery was required. A third ventriculostomy had been performed when increased intracranial pressure and neurological symptoms reappeared despite the previous VP shunt. Pregnancy was uneventful and vaginal delivery was anticipated. She presented in spontaneous labour at 40 wk. gestation. She declined analgesia throughout her four and a half hour labour A mediolateral episiotomy was performed to facilitate spontaneous delivery of a 4,182 g female infant. Mother and baby were discharged home without incident after two days. She denied any problems, including headaches, on follow up at two and four weeks. CONCLUSION: A review of the literature concerning pregnant patients with shunts found that both regional and general anesthesia has been used with no reports of complications directly related to anesthesia. No published cases describing labour analgesia for patients with third ventriculostomy were found. Two neurosurgeons advised that regional anesthesia was not contraindicated in such patients and that analgesia should be based on obstetrical considerations and the neurological status of the patient.