Goal Oriented Anaesthetic Management of a Pregnant Patient With Brain Tumor Posted for Emergency Caesarian Section and v-P Shunt

Abstract

BACKGROUND AND OBJECTIVE: Pregnant women with brain tumors are uncommon; however pregnancy itself may aggravate the natural history of an intracranial tumor and may even unmask a previously unknown diagnosis. Small studies remain an important source of knowledge and experience and hence this study aims to highlight the major issues and provide an overview to the case of the pregnant patients with brain tumor posted for emergency caesarean section including pre-anaesthetic evaluation, patient counseling per operative management and follow up. PRESENTATION, DIAGNOSIS, MANAGEMENT: A 23years old G2P1L1 lady presented at 41 weeks gestation and was posted for emergency caesarean section, indication being postdated pregnancy with previous caesarean section. She reported of being diagnosed with a brain tumor 6months back and that she has been suffering from severe headache associated with right sided facial palsy and bilateral hearing loss with severe papilledema. She confessed of her economic constraints because of which she couldn't get operated for so long. Following consultation between the anaesthetist, obstetrician and the neurosurgeon it was decided to proceed with caesarean section followed by V-P shunting under general anaesthesia. Rapid sequence induction and intubation was performed and was maintained with isoflurane, titrated to maintain the stability of mean arterial pressure until extraction. A live 2.6kgs female child was born with apgar scores of 8 and 9 at 1 and 5 mins respectively. Following extraction 10U oxytocin was given intramuscularly and 10U run as infusion in ringers lactate. Intra-operative analgesia was administered after extraction. After completion of caesarean section V-P shunting was performed by the neurosurgeon during which propofol and dexmedetomedine infusions were used. Post-operative period was uneventful. DISCUSSION & CONCLUSION: Anaesthetic management of brain tumor in pregnant women is mainly reliant on doctor's personal experience as no evidence based guidelines are available. General anaesthesia using thiopentone, propofol, fentanyl, dexmedetomedine and titrated dose of isoflurane as used in our case were found to be safe with adequate hemodynamic stability and post-operative pain control. A team approach involving the anaesthetist, obstetrician, neonatologist and neurosurgeon is recommended for appropriate management of such parturient.