Meningitis After Obstetric Spinal Anaesthesia

Abstract

A 28-year-old healthy gravida who delivered vaginally without anesthesia, requested regional block for manual removal of her retained placenta. Spinal block was performed in the sitting position after skin preparation with chlorhexidine and alcohol. A standard pack with sterile needles and syringes was used. After initial failure to perform a lumbar puncture with a 26-G needle, an introducer was employed and the needle inserted; clear CSF was obtained. Hyperbaric bupivacaine, 2.5 ml was injected. Eighteen hours later, the patient developed a severe frontal headache, worse on sitting, photophobia, shivering and pyrexia of 38°C which rapidly rose to 39.6°C. WBC was 19,800 and blood cultures were negative. Because the presumptive diagnosis was postpartum sepsis and post-dural puncture headache, treatment with antibiotics was initiated. However, 18 hours later, a marked positive Kernig's sign and left quadriceps weakness developed with a temperature of 37.4°C. Lumbar puncture revealed turbid CSF at a pressure of 230 mmH20 containing 6,640 polymorphonuclear leukocytes, 1250 red cells, protein 0.33 mg% and glucose 22 mg%. No bacteria were seen on Gram stain nor were any grown on culture. A diagnosis of either partially treated bacterial meningitis or chemical meningitis was made. She was treated with antibiotics for 7 more days and made an uneventful recovery.