Sir, We present the case of 22-year-old pregnant woman who underwent surgery in semi-prone position for a grade II Schwannoma. When admitted to our institute, she was in the second trimester of her first pregnancy. According to the last menstrual period and earlier ultrasound examination, the gestational age was 24 weeks. Her past medical, gynaecological, and neurological history was unremarkable. Her pregnancy had been uncomplicated until the 5th month. At approximately 20 weeks of gestation, the patient complained of difficulty in walking. Gradually she became bed ridden and was admitted in our institute as she was unable to walk. Magnetic Resonance Imaging of lumbar spine with whole spine screening revealed an intradural extramedullary dumbbell shaped lesion at D8-D9 level extending into the right D9-D10 neural foramina suggestive of nerve sheath tumour causing adjacent compression and displacement of the cord [Figures [Figures11 and and22]. Figure 1 Spinal cord tumour Figure 2 Spinal cord Schwannoma The patient's physical condition and that of the foetus were good, and all laboratory values were within normal limits. Due to the acute ongoing neurological deficit and patient being bed ridden, it was decided to electively remove the tumour. At the time of surgery, the patient was in the 24th week of gestation. Before induction, a wedge was placed under the right hip to displace the uterus to the left and increase venacaval blood flow. After preoxygenation, anaesthesia was induced with injection fentanyl 100 μg, and injection thiopentone 250 mg with vecuronium, 5 mg to facilitate orotracheal intubation. Anaesthesia was maintained with sevoflurane (0.5%), air and oxygen. In addition to standard monitoring (electrocardiography, pulse oximetry, oxygen analyser, end-tidal carbon dioxide) invasive arterial pressure was used. Foetal heart rate for prompt detection of foetal hypoxia was monitored using a cardiotocography fixed to the mother's abdominal wall; monitoring was continued throughout the operation and periodically during the first 12 h after operation. After judicious administration of saline to stabilise arterial pressure, the patient was anchored to the OR table in left lateral decubitus position with the help of adhesive tapes. Once the tapes were secured the whole table was given 90° tilt, hence the patient was in a semi-prone position. Proper gel paddings were used to prevent the pressure sores. Cardiotocography was monitored by the consultant obstetrician. Surgery was started in semi-prone position and the patient underwent D8-D9 laminectomy with excision of the intradural extramedullary grade II Schwannoma. Pathology confirmed the diagnosis of Schwannoma. Heart rate and arterial pressure remained stable during operation; mean arterial pressure throughout the operation was 90 mm Hg (range: 86–94 mmHg). Arterial blood gases were assessed periodically. Haemoglobin, packed cell volume, and plasma electrolyte concentrations remained within normal limits throughout the operation. The surgical procedure was completed in 6 h without complications. Patient was reversed by neostigmine and glycopyrrolate and extubated safely. The patient was then shifted to intensive care unit for further monitoring and transferred to the surgical ward on the 1st postoperative day. Subsequent obstetric and ultrasound checks were normal. The patient was discharged on the 10th post operative day and mild improvement in the neurological condition was seen. Caesarean section was performed electively during the 35th gestational week under general anaesthesia with delivery of a healthy female child of 2.5 kg. Many anaesthesiologists and surgeons are reluctant to operate on pregnant women because of the risk of inducing premature birth or miscarriage or otherwise damaging the foetus. However, when faced with the clinical indication for urgent or emergency surgery, pregnancy should not affect the decision to proceed.[1] Furthermore, despite the understandable concern, premature labour does not seem to be a frequent outcome of surgery during pregnancy[2] and foetal mortality and morbidity are minimal when surgery is unavoidable.[3] However, the data refer mainly to abdominal surgery (often laparotomy), and recent reports on spinal cord tumours in pregnancy are scarce, in view of the rarity of the association.[4] As described here, spinal cord tumour can become an emergency, in which case delay in treatment could jeopardise the life of the woman and the foetus. Our case was also distinguished by the site of lesion (intradural extrameduallary), and operating position (semi-prone position), and long duration of the operation. There are few reports in the literature regarding positioning of pregnant patients for surgery, except for delivery itself.[5] We decided to operate with the patient in a semi-prone position, which was made possible by anchoring the patient in left lateral decubitus position to the OR table and giving the OR table a 90° left tilt. Management of intradural extramedullary tumours in pregnancy must be individualised. The patient's physical condition, gestational age, site, size and type of tumour, and neurological signs, in addition to the patient's wishes, must be considered in the decision-making process.[6]
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Dec 23, 2015
Takaaki Saito + 1
Open Access
