OB Lecture 2: OB Anesthesia Complications

Question 1

Intrinsic Obstetric Paralysis:

Answer 1

• Most common cause is cephalopelvic disproportion which results in lumbosacral trunk compression.
• Most deficits resolve with in 72 hours
• weakness or numbness in legs.

Question 2

Postpartum backache:

Answer 2

• 75% of parturients describe backache, new onset for 60% (most likely the result of carrying a fetus and lumbar lordosis and laxity of sacrococcygeal, sacroiliac, and pubic joints)
• soft-tissue trauma from regional is usually self-limiting.
• Be sure to exclude serious pathology first: disc-prolapse, sacroilitis, osteomyletitis, tumor, aortic dissection, septic pelvis, thrombophlebitis.

Question 3

Complications of neuraxial blocks:

Answer 3

• Nerve injury
  
  • Epidural hematoma
  • Epidural Abscess
  • Chemical nerve injury (injected into wrong spot)
  • needle trauma
  • positioning injury (intrinsic obstetric palsy)
• Postdural Puncture HA (PDPH)
• High or total spinal Anesthesia

Question 4

Epidural Hematoma:

Answer 4

• Rare complication (usually post surgical, not OB related) and usually associated with hemostatic abnormality or coagulopathy.
• Can occur with block placement or catheter removal. Insertion and removal should only occur when coagulation function is normal.

Question 5

At what coagulation function is it safe to do a neuraxial block?

Answer 5

• Pt must not have Hx of bleeding problems, and no s/s of Pregnancy Induced HTN (PIH) and not on Anticoagulants.
• For patients with PIH, a platelet count of over 100,000 and normal PT, PTT is Required. Make certain that platelet count is not dropping rapidly as in HELLP syndrome.
• If pt on LMWH, follow ASRA guidelines, consider IV analgesia.

Question 6

ASRA Guidelines: Avoid Neuraxiel block for ___ hours if therapeutic anticoagulated with LMWH.

Answer 6

24 hours

Question 7

ASRA Guidelines: Avoid Neuraxiel block for ___ hours if prophylactic anticoagulated with LMWH.

Answer 7

12 hours

Question 8

Do not remove catheter until at least ___ hours after last dose of LMWH.

Answer 8

12 hours

Question 9

With Neuraxial block and LMWH, avoid concurrent use of ____ or _____.

Answer 9

NSAIDS or Anticoagulants.

Question 10

Signs and symptoms of epidural hematoma:

Answer 10

• Bilateral leg weakness
• incontinence
• absent rectal sphincter tone (incontinent of stool)
• back pain

If hematoma suspected, pt must get a STAT CT or MRI.
Surgical decompression must occur within 6 hrs for full neuro recovery to occur.

Question 11

Signs & Symptoms of Epidural Abscess:

Answer 11

• Severe back pain, worse with flexion.
• Severe local tenderness to palpation
• Fever, malaise, meningitis-like HA with stiff neck.
• Elevated WBC, increased ESR and +blood cultures
• progression over hours to days to neuro deficit or osteomyelitis.
• incubation period is 4-10 days for symptoms to manifest (usually back pain, loss of function).
• Tx: Abx, laminectomy. 6-12 hour window before permanent damage.

Question 12

The conus medullaris located at:

Answer 12

T12-L3 (most commonly L1-L2)

Question 13

post partum foot drop is commonly caused by what?

Answer 13

Compression of the common peroneal nerve or brow compression of the lumbosacral trunk via lithotomy stirrups

Question 14

Difficulty climbing stairs and numbness over quads are common signs of what nerve injury?

Answer 14

Femoral nerve compression from flexed hips or fetal head compression during delivery.

Question 15

Obturator nerve injury can manifest as:

Answer 15

decreased sensation over upper, medial thigh and weak hip adduction.

Question 16

Post Dural Puncture HA (PDPH) onset is:

Answer 16

Typically 12-48 hours after dura puncture. Duration is a few days to weeks. Usually self limiting with spinal needles, may become chronic from larger epidural needle.