Spinal anaesthesia for Caesarean section in an achondroplastic dwarf

Abstract

A 26-year-old primigravid achondroplastic dwarf was to be delivered by elective Caesarean Section at 36 weeks gestation. At 21 weeks gestation she had suffered a deep venous thrombosis and pulmonary embolism, and was treated initially with intravenous heparin followed by warfarin. At 33 weeks gestation, she was re-admitted to the maternity unit and the warfarin was substituted by intravenous heparin to continue until delivery. The pregnancy was further complicated by polyhydramnios. Examination revealed the typical features of achondroplasia. She weighed 44 kg, and was 117 cm tall with a relatively normal spinal length of 52 cm. Subarachnoid block using a microspinal catheter was chosen to provide anaesthesia for the section. Heparin was stopped 24 h before surgery, and a clotting screen was normal on the day. Oral ranitidine 150 mg was given the night before, and on the morning of surgery. A circulatory preload of 6 ml.kg-' of Ringer lactate solution was given. With the patient in the left lateral position, a 32 gauge catheter was passed 4 cm into the subarachnoid space via a 25 gauge needle at the L2-3 interspace. An initial infusion of 0.5 ml hyperbaric 0.5% plain bupivacaine was given through the catheter. Within 20 min, a bilateral T, block had developed. Blood pressure decreased to 60/34 mmHg and was treated with 12 mg intravenous ephedrine. There was a delay in starting surgery during which the block receded over a 15 min period to T, on the left and T,, on the right. A further 0.5 ml local anaesthetic was given which restored the block to T, bilaterally. Surgery was begun with the patient in the wedged supine position.A lower uterine segment Caesarean section was performed, and a live, female achondroplastic child, with good Apgar scores, was delivered 14 min after skin incision. Forty minutes after the second dose o,f bupivacaine, a further 0.3 ml was given. A total of 0.1 mg diamorphine was given via the catheter to provide postoperative analgesia. The motor and sensory blocks wore off within 30 min of the end of the procedure. The diamorphine provided excellent analgesia in the first 24 h. Mother and baby were discharged after I days. There are few reports describing the use of central blockade in the anaesthetic management of achondroplastic patients [l, 21. If spinal anaesthesia is to be undertaken, we would recommend the use of a microspinal catheter, since this allows small incremental doses of local anaesthetic to be given when necessary.

Anaesthesia for caesarean section in a patient with diastrophic dwarfism

“…At 76 cm tall, she was very short (much shorter than the dwarfs reported in the literature [8][9][10][11][12][13][14] ) and she had clinical signs indicating a difficult airway. It was evident that she would need a caesarean section and the timing of this was dependent on her respiratory function.…”

Failed regional anesthesia with reduced spinal bupivacaine dosage in a parturient with achondroplasia presenting for urgent cesarean section

“…4,6 Despite these drawbacks however, epidural and continuous spinal anesthesia have been recommended by some for elective cesarean section in the appropriate patient and situation. [3][4][5]8,14 Nevertheless, unpredictable dose requirement for epidural and spinal anesthesia has been reported. [2][3][4][5] Because the volume and dose needed for an adequate surgical block are difficult to determine because of short stature and the features mentioned above, a titratable technique such as an epidural, combined spinal epidural (CSE) or continuous spinal can be considerably more successful than a single-shot spinal, allowing for initial safe titration and supplementation, should the initial dose be ineffective.…”

Anesthetic management for Cesarean delivery in parturients with a diagnosis of dwarfism

“…[8][9][10]12,14,[16][17][18][19][20] Our study provides an evaluation of 15 deliveries in 13 parturients with a diagnosis of dwarfism and their anesthetic management for Cesarean delivery. This review better characterizes the responses to different anesthetic techniques in this patient population than provided by single case reports in previous publications.…”