Journal: Br J Anaesth 99(6):855-857, 2007. 11 References
Reprint: Dept of Neuroanaesthesiology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi 11029 India (H Prabhakar, MD)
Faculty Disclosure: Abstracted by J. Joyce, who has nothing to disclose.
Neurological complications in the peripartum period are commonly due to eclampsia, intracranial hemorrhage, cerebral venous thrombosis, epilepsy, and myasthenia gravis. Quadriplegia as a result of spontaneous spinal epidural hematoma (SSEH) in the post-partum period is a rare occurrence, more so in the absence of predisposing factors. The aim of this report was to highlight SSEH with cord demyelination as a possible cause of quadriplegia in the post-partum period.
Quadriplegia in the immediate post-partum period is a rare occurrence, particularly in the absence of known predisposing conditions such as pre-existing coagulopathies, anticoagulant therapies, vascular malformations, arteritis, eclampsia or iatrogenic causes such as spinal and epidural injections for labor analgesia or cesarean section. SSEH is also a rare occurrence during pregnancy, with only 6 cases reported in the literature since 1900.
All possible causes of an epidural hematoma were ruled out by investigations in this patient. The progression of the event beginning with localized radicular pain in the neck and arms progressing to motor weakness and sensory deficit over a period of 2 days was consistent with the diagnosis of an epidural hematoma/hemorrhage within the cord. The etiology of SSEH remains obscure; there is controversy whether the bleeding is arterial or venous in origin. SSEH in pregnancy has been hypothesized to be caused due to rupture of a pre-existing pathological venous wall in the presence of elevated intra-abdominal pressure.
Another hypothesized cause is that hemorrhage in the cervical and upper dorsal cord was arterial in origin. Previous investigators have concluded that bleeding from a low-pressure venous system could not expand so rapidly and cause compression. They held that the altered hormonal milieu of pregnancy was responsible for changes in the vessel wall and ligaments leading to hematoma. These authors hypothesize that in the absence of other known predisposing conditions, the hematoma could have been precipitated by the rupture of a weakened epidural artery, possibly by some innocuous trauma to the cervical region which initially went unnoticed by the patient.
Multiple sclerosis (MS) and acute transverse myelitis (ATM) are the two common causes of demyelination in the peripartum period leading to acute onset muscle weakness. It is likely that acute onset demyelination in this patient could have been precipitated by the immuno-modulatory effects of altered hormonal milieu of the post-partum period. |
