INTRA-OPERATIVE

Chapter 23

Meningioma During Pregnancy

Dr. Vasanthi Vidyasagaran*

Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India

*Correspondence: Vasanthi.vidyasagaran@gmail.com

Dr. Vasanthy Vidyasagaran Muralidharan

Anaemia or Hydrocele
Anaemia or Hydrocele

A 32-year-old woman, was posted for elective LSCS at 36 weeks of pregnancy, indication being the presence of a meningioma.

She had increasing headache over the preceding three weeks, investigated for preeclampsia and ruled out. She had been referred to the neurologist. CT scan revealed a benign meningioma. The plan was elective section under general anaesthesia, deliver the baby, and then to control the symptoms of tumour by steroids before considering neurosurgery. She was admitted a week earlier. However, she developed labour pains before scheduled date and had to be taken up for emergency LSCS.

The aim was to control the stress, pain and make sure mother and the baby were safe.

Her blood investigations were normal and vitals stable. BP=130/70, HR=88/min, and chest was clear. General anaesthesia was discussed with the patient and her relatives, and possible intensive care in the postoperative care.

Concerns:

  1. Pregnant lady with cerebral space occupying lesion with symptoms of raised intracranial pressure
  2. Care for the mother and the baby
  3. Maintain hemodynamic stability, ensure end organ perfusion including vital organs and uterine circulation
  4. Prevent increase in intracranial pressure

General anaesthesia was induced with Thiopentone 250 mg, and muscle relaxant Atracurium 30 mg was used. Suxamethonium was deliberately avoided. Trachea was intubated with size 7.0 cuffed tube. Fentanyl 100 mcg and IV Paracetamol were given. Sevoflurane, Oxygen and air were used to maintain anaesthesia. N2O was avoided. Baby was delivered within 5 minutes, and had a good Apgar score.

Low dose Syntocinon 10 units as slow intravenous drip was administered.100 ml of 20% mannitol was given to prevent ICT. Uterus contracted well and no more drugs were necessary. Surgery was completed in 45 minutes. Rectus sheath block was also given for pain relief. Extubation was done smoothly with Dexmedetomidine 20 mcg slow IV. The patient recovered well with stable vitals. She was transferred to high dependency unit for postoperative monitoring. Fluid balance was maintained and there were no neurological sequelae before shifting to ward. She was given one dose of 20% mannitol, and 8mgs dexamethasone to prevent increase in intracranial pressure.

Discussion

Meningiomas appear to be the most common benign tumour, and they continue to grow during pregnancy. Unless they present with progressive neurological deficits, treatment is mainly conservative in pregnant patients. Acoustic neuromas and pituitary adenomas are other common types of intracranial tumours. Diagnosis of an intracranial mass should not be confused with hyperemesis gravidarium, eclampsia or puerperal psychosis.

Urgent neurosurgical intervention is warranted in patients with malignant tumours, active hydrocephalus or benign intracranial tumour such as meningioma associated with signs of impending herniation, with progressive neurological deficits. Unresectable or recurrent meningioma may need radiotherapy and Mifepristone.

Management plan for each patient must be tailored based on clinical findings, pathology, gestational age, Safety of the mother must be the priority. The anaesthetic implications in management include:

  1. Pregnancy related issues – care for two lives during surgery
  2. Intracranial space occupying lesion with symptoms of raised intracranial pressure
  3. Subarachnoid blockade has potential to cause sudden drop in ICP, leading to coning and cause catastrophe
  4. General anaesthesia with risk and benefits explained to patient and relatives well before surgery allows for them to understand the situation.
  5. Avoid drugs that lead to raised ICP
  6. Patients presenting with neurological symptoms like seizure, visual deficit, or neurological deficit would be higher surgical and anaesthetic risk carrying significant risk of morbidity and mortality.

If acute and severe maternal neurological deterioration develops, a life-saving neurosurgery may become mandatory.

References

  1. Rajkumar S, et al. Neurosurgery and pregnancy. J Neuroanaesthesiol Crit Care. 2014;1(3).
  2. Dumitrescu et al. Pregnant woman with an intracranial meningioma – case report and review of the literature. Romanian Neurosurg. 2014;XXI(4):482-9.
  3. Sahu S, et al. Management of pregnant female with meningioma for craniotomy. J Neurosci Rural Pract. 2010;1(1):35-7.
  4. Wang LP, et al. Neuroanesthesia for the pregnant woman. Anesth Analg 2008;107:193-200.
  5. Chang L, et al. Anesthesia for cesarean section in two patients with brain tumours. Can J Anaesth. 1999;46:61-5.
  6. Goldberg M, Rappaport ZH. Neurosurgical, obstetric and endocrine aspects of meningioma during pregnancy. Isr J Med Sci. 1987;23:825-8.

Chapter 24

Minor Procedure in an Obese Child: Unexpected Cause of Airway Obstruction

Hip Spica placement in baby

A 14 months old child was posted for closed reduction and Hip Spica placement for congenital hip dysplasia. He weighed 18 kg. He had no other significant clinical history. Did not appear to have any other associated syndrome, or any congenital abnormality. Chest was clear. He had no known allergies. Haematological investigations were within normal limits. He was immunized.

The plan was to give him general anaesthesia through mask and maintain airway while the surgeon performed the procedure. The procedure usually lasts about ten minutes. The child was induced using Halothane, IV line in place. Glycopyrrolate 0.05 mg IV was given. Mask ventilation was maintained with Halothane/Oxygen/Nitrous oxide.

Procedure was completed in about 15 min. Spontaneous breathing was maintained. However, as the baby woke up, the breathing was very jerky. Jaw thrust was applied to clear the airway, but an obstructive pattern in breathing was still noticed. Breath sounds were diminished, but no adventitious sounds. This was suspected to be due to upper airway problem. Direct laryngoscopy was done to check for the cause. The tonsils were enlarged on both sides, almost reaching the midline, causing airway obstruction.

Once this was recognized as the cause for obstruction, head was turned to one side, and mask held with mild CPAP. This was not sufficient to clear the airway completely. Saturations were maintained at 92- 93%. A small size 3.0 endotracheal tube was gently passed through right nostril, and he was oxygenated. Spontaneous ventilation was smooth and rhythmic after this intervention. Saturation picked up to 100%. Child recovered well and was shifted to recovery.

Discussion

The anaesthetic concerns in an obese child may include:

    1. Difficult venous access
    2. Difficulty in bag mask ventilation and intubation
    3. Rapid desaturation and hypoxia due to poor reserves
    4. Difficulty in obtaining a perfect fit with a SGA

In addition, if the child has a large tongue, placement of the SGA can become difficult and traumatic. One should understand the limitations of a SGA and not use it blindly on all patients, or for all surgeries.

  1. Ventilation with endotracheal tube and extubation once the child is awake may be safer. Airway adjuncts may help save situations.
  2. Postoperative analgesia may be an issue

Upper airway assessment in a small child is not done thoroughly as a routine unless the child is syndromic and we have obvious anticipated difficult airway problems. Tonsillar enlargement in a one- year old child is a very rare occurrence. The peak enlargement is usually quoted to occur between 2-4 years of age. In this child, enlarged tonsils were complicated by the fact that child was obese and had narrow oral and nasopharyngeal space.

Obstruction was probably not recognized during the procedure because the child was in Spica position with head held in hand and airway maintained in slightly extended neck position. Obstruction became pronounced once child was placed on the table supine. Mask ventilation with CPAP was not sufficient. Patient could not be placed in lateral position due to Spica. At that moment, timely placement of endotracheal tube as nasopharyngeal airway helped, bearing in mind not to cause trauma to structures in nasopharynx.

References

  1. El-Metainy S, et al. Incidence of perioperative adverse events in obese children undergoing elective general surgery. Br J Anaesth. 2011;106:359-63.
  2. Smith HL, et al. Childhood obesity a challenge for the anaesthetist. Paediatr Anaesth. 2002;12:750-61.
  3. Owen J, et al, Childhood obesity and the anaesthetist. Contin Educ Anaesth Crit Care Pain. 2012;12(4):169-75.

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