Extensive deep vein thrombosis in a young parturient ...

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pharyngeal airway, failure of neuraxial anaesthesia because of thoracolumbar deformity and spinal canal stenosis[1] leading to controversy over the dose requirement for spinal anaesthesia. We describe the successful administration of spinal anaesthesia and the rationale for the dose of hyperbaric bupivacaine injected in an obese achondroplasic parturient. A 24–year-old primigravida with cephalopelvic disproportion underwent emergency caesarean section at 38 + 2 weeks of gestation in view of foetal distress. Her height was 126 cm, weight was 64 kg (prepregnancy weight of 55 kg) and her body mass index (BMI) was 34.6 kg/m2 with lumbar lordosis but normal thoracic spine. Her Malampatti score was 3, with normal interincisor and thyromental distance. Antacid prophylaxis was administered, preloading with 500 ml of normal saline done and pulse oximetry, electrocardiogram (ECG) and an automatic blood pressure cuff attached for monitoring. 1.6 ml of 0.5% of hyperbaric bupivacaine (8 mg) was administered in the L3-L4 intervertebral space using a 26 G Quinckes needle. Sensory blockade extended to T4 and the patient maintained haemodynamic stability intraoperatively.

bupivacaine with 10 µg of fentanyl,[3] but these studies reported a transient decrease in blood pressure, or 1 ml of 0.5% hyperbaric bupivacaine with 10 µg of fentanyl.[5] But, none of the studies gave any rationale for drug dosage of intrathecal bupivacaine used. The probability of failed spinal is higher in achondroplastic patients but, still, parturients undergoing caesarean section should not be denied regional anaesthesia. The dose of intrathecal bupivacaine injected must be based on the height of the patient, with corrections made for the presence of spinal canal stenosis. However, no reduction in the dose is needed for obesity. Tanvir Samra, Sujata Sharma Department of Anaesthesia and Intensive Care, Dr Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, Connaught Place, New Delhi - 110 001, India Address for correspondence Dr. Tanvir Samra, C-II/77 Moti Bagh 1, New Delhi - 110 021, India. E-mail: [email protected]

REFERENCES 1. 2.

The factors considered when calculating the dose of hyperbaric bupivacaine in our patient were height, weight, spinal anatomy and pregnancy, as these are important determinants of intensity and duration of spinal block. The minimum effective dose of intrathecal bupivacaine providing effective spinal block in 95% of the women undergoing caesarean section is 0.06 mg/cm height[2] and, based on this for our patient (height 126 cm), the dose of bupivacaine was 7.56 mg or, approximately, 8 mg (1.6 ml of 0.5%). Achondroplasia is associated with spinal canal stenosis and, as proposed in a similar case report by Ravenscroft et al.,[3] a 30% reduction in the dose of intrathecal drugs should be carried out in parturients with achondroplasia. But, in our case, no reduction in dose was performed as a magnetic resonance imaging of the spine did not show any evidence of spinal canal stenosis. It has been suggested by imaging that the lumbosacral cerebrospinal fluid volume varies inversely with BMI. But, in spite of this, clinical studies by Norris[4] demonstrated that the dose of intrathecal bupivacaine for caesarean delivery is similar in obese and normal weight women. Previous studies have used 1.3 ml of 0.5% hyperbaric 482

3. 4. 5.

Berkowitz ID, Raja SN, Bender KS, Kopits SE. Dwarfs: pathophysiology and anesthetic implications. Anesthesiology 1990;73:739-59. Danelli G, Zangrillo A, Nucera D, Giorgi E, Fanelli G, Senatore R, et al. The minimum effective dose of 0.5% hyperbaric spinal bupivacaine for cesarean section. Minerva Anestesiol 2001;67:573-7. Ravenscroft A, Govender T, Rout C. Spinal anaesthesia for emergency caesarean section in an achondroplastic dwarf. Anaesthesia 1998;53:1236-7. Norris MC. Patient variables and the subarachnoid spread of hyperbaric bupivacaine in the term parturient. Anesthesiology 1990;72:478-82. Mitra S, Dey N, Gombar KK. Emergency caesarean section in a patient with achondroplasia: an anesthetic dilemma. J Anesth Clin Pharmacol 2007;23:315-8.

Extensive deep vein thrombosis in a young parturient with a brief use of oral contraceptive pills DOI: 10.4103/0019-5049.71031

Sir, Because of misleading publicity by the media and over-the-counter availability of oral contraceptive (OC) pills, its use is increased all over the world, which can result in fatal complications like deep vein Indian Journal of Anaesthesia | Vol. 54| Issue 5 | Sep-Oct 2010


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thrombosis (DVT). DVT occurs in 2–3/1000 patients who give history of use of OC pills for various reasons. As pregnant patients are from younger age group, risk of DVT often gets ignored during the pre-anaesthetic checkup. Once diagnosed, these patients are managed by conventional anticoagulation which may lead to change in anaesthesia technique and becomes a challenge for the anaesthetist during emergencies. A 28-year-old female, weighing 48 kg, with a diagnosis of 3rd gravida with extensive DVT, was scheduled for elective Lower Segment Caesarean Section (LSCS). She had a history of use of OC pills on and off for irregular periods, with no other co-morbidities. Laboratory investigations were normal except raised activated partial thromboplastin time (APTT). Lupus anticoagulants were on higher side. X-ray chest, electrocardiogram (ECG) and echocardiography were normal. Venous Doppler showed deep venous thrombosis of external iliac, femoral, poplitial and anterior tibial veins. There was presence of extensive thrombus in great saphanous vein. She was on low molecular weight heparin (LMWH) which was stopped a day before surgery. Also, 2 units each of compatible blood and fresh frozen plasma (FFP) were reserved for emergency use. General anaesthesia was planned. After taking informed consent, she was shifted to operation theatre for caesarean section. General anaesthesia was induced with thiopentone sodium 250 mg and succinyl choline 100 mg intravenously. Trachea was intubated with cuffed endotracheal tube of size 7.0 mm. Anaesthesia was maintained with O2:N2O (40:60), and vecuronium bromide (4 mg). After delivery of baby, Inj. Fentanyl 100 mcg, Oxytocin 10 U and Inj. Midazolam 1 mg IV were administered. She received approximately 1000 ml of crystalloid intraoperatively. Total blood loss was approximately 500 ml. At the end of surgery, reversal of neuromuscular blockade was achieved with Inj. Neostigmine 2.5 mg and Inj. Glycopyrolate 0.4 mg. After extubation, she was shifted to PICU and closely monitored. LMWH was withheld till the next day, considering the risk of postoperative bleeding. Her subsequent course in the hospital was uneventful and she was referred to the cardiologist for further management. Every patient with even a brief history of use of OC pills should be evaluated thoroughly. There is an increased risk of VTE due to OC use in women with elevated factor VIII, and raised level of the coagulation factor and OC use seem to have a synergistic effect.[1] Indian Journal of Anaesthesia | Vol. 54| Issue 5 | Sep-Oct 2010

DVT may give rise to pulmonary embolism, which has a maternal mortality of 1:100,000.[2] In women with clinically suspected DVT, the diagnosis should be confirmed by investigation. Initial investigation is by Doppler ultrasonography. If inconclusive, serial testing by ultrasonography or contrast venography (with abdominal shielding) can be done. D-dimmer values should be checked to confirm the diagnosis. Blood should be checked for APTT; complete blood picture, thrombophilia screen, coagulation studies, urea and electrolytes and liver function tests need to be taken to exclude renal or hepatic dysfunction.[3] A prolonged APTT should raise the suspicion of a lupus anticoagulant being present. Following confirmation of diagnosis of DVT, the patient should be informed about the diagnosis and the complications. Such patients might be on anticoagulants which interfere with the anaesthesia techniques and pose a challenge to the anaesthetist. Problems encountered by the anaesthesiologist in the management of symptomatic patients include: 1) risk of intraoperative bleeding and risk of postpartum haemorrhage because of use of LMWH and 2) risk of pulmonary embolism if anticoagulants are stopped. Our anaesthetic goals should be as follows: 1) In view of the presence of extensive DVT, to continue LMWH till 12 hours before surgery. 2) Reserve adequate quantity of compatible blood and FFP. If APTT is still prolonged, then FFP should be administered to normalise the APTT. 3) Ensure that anti embolic stockings are in place before caesarean section. 4) Keep the patient well hydrated. 5) Opt for general anaesthesia instead of spinal/ epidural. Regional anaesthesia (epidural or spinal) is to be avoided during anticoagulation treatment because of risk of spinal haematoma. Recommence anticoagulation treatment at the same dose regimen given antenatally in the postpartum period. Neither oral anticoagulants nor heparin appears in breast milk to any significant degree and breast feeding is not contraindicated. LMWH is the agent of choice as it binds less to platelet factor 4, substantially reducing the risk of heparin483


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induced thrombocytopaenia.[4] Patients with a history of previous VTE and acquired thrombophilia (antiphospholipid syndrome) have up to 70% chances of recurrent thrombosis, even higher in pregnancy. Some of these women will be on long-term oral anticoagulants outside pregnancy. These women need antenatal, intrapartum and postnatal prophylactic thromboprophylaxis. To conclude, proper evaluation of patients with history of even brief use of OC pills is required to decide on the anaesthetic technique and proper and adequate perioperative care to prevent maternal morbidity and mortality. Jayashree C Patki, C Naresh K Reddy Department of Anesthesiology, Krishna Institute of Medical Sciences, Secunderabad - 500 003, India

Address for correspondence: Dr. Jayashree Patki, Swagat-2-1-437/5,Street No. 5, Nallakunta, Hyderabad - 500 044, India. E-mail: [email protected]

REFERENCES 1.

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Legnani C, Cini M, Cosmi B, Poggi M, Boggian O, Palareti G. Risk of deep vein thrombosis: interaction between oral contraceptives and high factor VIII levels. Haematologica 2004;89:1347-51. De Swiet M. Thromboembolic disease. In: James DK, Steer PJ, Weiner CP, Gonik B, editors. High risk pregnancy: management options. 2nd ed. London: Harcourt; 1999. p. 901-9. Royal College of Obstetrics and Gynaecology (RCOG). Clinical Green Top Guidelines - 'Thromboembolic disease in pregnancy and the puerperium: Acute Management Feb 2007. p. 28. Greer IA, Nelson-Piercy C. Low-molecular weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy. Blood 2005;106:401-7.

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Indian Journal of Anaesthesia | Vol. 54| Issue 5 | Sep-Oct 2010