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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 1  |  Issue : 2  |  Page : 89-91

Spinal medulloblastoma in pregnancy: A pandora of challenges for the anesthesiologist


1 Department of Neuroanaesthesiology and Critical Care, AIIMS, Delhi, India
2 Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
3 Department of Anaesthesiology, SGRRIMS, Dehradun, Uttarakhand, India

Date of Submission22-Sep-2022
Date of Acceptance01-Nov-2022
Date of Web Publication02-Dec-2022

Correspondence Address:
Dr. Sharmishtha Pathak
Department of Neuroanaesthesiology and Critical Care, AIIMS, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jica.jica_28_22

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  Abstract 

Tumors of the spinal column, meninges, nerve roots, or the cord parenchyma itself may compress and damage the spinal cord resulting in neural deficits. The presence of spinal cord tumor itself in pregnancy is a rare occurrence. Rapidly progressive neurological involvement due to compression should be considered for immediate decompression. The specific positioning for surgery and inaccessibility to the airway during surgery makes all spinal surgeries technically challenging for the anesthesiologist. The presence of pregnancy along with this disease further complicates patient management. We present the case of a 24-week-old pregnant female who reported to emergency with decreased sensation in her lower limbs and urinary retention. She was operated previously for cranial medulloblastoma and was on regular follow-up. Magnetic resonance imaging spine revealed multiple intradural extramedullary masses at the D3-4, D8-9, and D10-D11 vertebral levels. Considering her pregnancy and increased risk of surgery during this condition, only the mass causing her symptoms was decided to be operated upon (D10-11). The surgery was done in the prone position, during which, fetal well-being was insured by the obstetric team using transabdominal ultrasonography. Careful padding of pressure points was done; frames on the Allen table were placed in a manner to avoid any pressure on the abdomen during the surgery. The surgery was uneventful, and the patient was successfully reversed and extubated. Fetal heart rate was monitored perioperatively at regular intervals, and ultrasonographic assessment was done by the obstetric team once the patient was extubated. This case highlights the requirement of training the professionals for tackling nonobstetric surgery in a pregnant patient. The increased awareness and education in society regarding perioperative care issues will bring forth new challenges and thus we need to be more prepared for handling such cases.

Keywords: COVID, medulloblastoma, pregnancy, prone position, spinal surgery


How to cite this article:
Pathak S, Agrawal S, Biswas K. Spinal medulloblastoma in pregnancy: A pandora of challenges for the anesthesiologist. J Ind Coll Anesth 2022;1:89-91

How to cite this URL:
Pathak S, Agrawal S, Biswas K. Spinal medulloblastoma in pregnancy: A pandora of challenges for the anesthesiologist. J Ind Coll Anesth [serial online] 2022 [cited 2023 Feb 3];1:89-91. Available from: https://www.jicajournal.in//text.asp?2022/1/2/89/362614


  Introduction Top


Medulloblastoma is a relatively common brain tumor of childhood, but its occurrence in adults is rare. It has a propensity for neuraxial spread through cerebrospinal fluid pathways.[1],[2] Due to advancements in surgery, chemotherapy, and radiotherapy, the prognosis and survival of patients suffering from medulloblastoma have improved multifold.[3] The presence of pregnancy in patients suffering from spinal cord metastasis further complicates the matter. The induction of general anesthesia and prone positioning for surgery in a pregnant patient poses many concerns.[4] Therefore, there are very specific indications for surgery and a limited number of reports of successful anesthetic management in this subset of patients. We present a case report of successful anesthetic management of a pregnant patient presenting with paraparesis and urinary retention.


  Case Report Top


A 28-year-old multiparous pregnant woman with 24 weeks of gestation was admitted with complaints of paraparesis and urinary retention. Careful history taking revealed that her limb weakness had started 2 months back, and at present, she could barely move them. The routine investigations revealed her COVID-19 positive status (reverse transcriptase–polymerase chain reaction positive), which meant a delay in definitive surgery till she became COVID-19 negative. She was classified as having mild-to-moderate disease (oxygen saturation remained around 92%–94% during the course of the infection).[5] After 14 days of oxygen therapy, steroids, and low-molecular-weight heparin, the patient recovered from COVID-19 with no post-COVID sequelae. She was further examined and her past history revealed surgery for cranial medulloblastoma 5 years back. Magnetic resonance imaging spine was done which revealed multiple intradural extramedullary masses at the thoracic (T) 3-4, T8-9, and T10-T11 vertebral levels. The risk–benefit assessment was carried out in consultation with neuroanesthesia, neurosurgery, and obstetric teams, and taking her pregnancy into consideration, she was not a suitable candidate for receiving chemotherapy or radiotherapy and since the symptoms were acute and affecting her daily activities, only the lesion responsible for her symptoms (i.e. T10-T11) was planned to be excised. The patient was carefully assessed by the obstetric team with ultrasonography (USG) and tomography at regular intervals to accurately assess fetal well-being. The anesthesia and surgical plan were discussed preoperatively with the complete team, and it was decided that the obstetrician would also ensure fetal well-being by performing USG at constant intervals (preoperatively before induction, immediately after induction, after turning supine following surgical closure, and after extubation) perioperatively. The preoperative assessment was unremarkable. She was average built, weighing 63 kg with a body mass index of 18.9 kg/m2. The patient was explained in detail regarding the risks associated with surgery pertaining to fetal distress or even demise, and after understanding the risks, she consented for anesthesia and surgery. Fasting instructions were given to the patient, 8 h for fatty meals, 6 h for nonfatty meals, 4 h for liquids, and 2 h for water. She was given antacid prophylaxis in the form of tablet ranitidine 150 mg in the night prior and on the morning of surgery and sodium citrate 0.3M 30 ml orally 30 min before shifting to the operation room (OR). She was wheeled into the OR the next day and standard ASA monitors were applied including electrocardiography, noninvasive blood pressure, and SpO2. Rapid sequence induction propofol 2 mg/kg and rocuronium 1 mg/kg and the trachea were intubated with a size 7.0 mm cuffed endotracheal tube. Anesthesia maintenance was done using a 50% mixture of oxygen and air, sevoflurane to achieve MAC between 0.9 and 1, and 5-mg rocuronium bolus to maintain muscle relaxation. An arterial line was placed in the left radial artery for beat-to-beat monitoring of blood pressure. A mean blood pressure >70 mmHg was targeted at all times during the surgery to ensure that placental circulation is not compromised. A surface temperature probe was placed to maintain the temperature between 35°C and 37°C. The EtCO2 was kept between 35 and 38 mmHg to achieve a PaCO2 of 34–37 mmHg. Pressure points were padded with cotton rolls, and eyes were padded to prevent pressure necrosis [Figure 1]. The obstetric team performed USG to confirm fetal well-being before positioning and equipment for delaying labor (medications such as salbutamol and calcium channel blockers including nifedipine and magnesium sulfate) and conducting emergency cesarean section were kept on standby. A neonatologist was on standby with an incubator cum ventilator and appropriate-sized endotracheal tubes in the event of emergency lower segment cesearean section. The pressure pads on Allen table were wrapped with more cotton and were positioned in such a way so as to prevent compression of the abdomen. The patient was carefully positioned prone on Allen table and her head rested on a foam headrest. Once positioned, the abdomen was checked for freeness to avoid any pressure on the gravid uterus and ascertain fetal well-being. Pressure-controlled ventilation was instituted with pressure support of 12 (tidal volume generated: 450–470 ml), positive end-expiratory pressure of 4 mmHg, and a respiratory rate of 14/min. The patient was carefully hydrated with a balanced salt solution using pulse pressure variation and stroke volume variation as the guiding parameters. Serial arterial blood gas analysis was done to monitor the acid–base status, lactate, and hemoglobin levels. Hemodynamic stability was maintained throughout the surgery. T10-11 laminectomy with excision of the tumor was performed in 3 h with 350 ml blood loss. Once the surgery was over, the patient was returned to the supine position, USG was performed to ascertain fetal well-being, and the patient was extubated successfully once fully awake. She started improving neurologically and was discharged with improved function in the lower limb and a viable fetus with advice for regular follow-up. The patient reported 1 month later to neurosurgery outpatient department with complete improvement in the motor power of lower limbs, and she delivered a healthy baby.
Figure 1: Patient after prone positioning on Allen's table, extra padding placed on the chest and pelvic supports, abdomen kept free, abdominal shield used when X-ray was taken once after positioning

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  Discussion Top


Spinal tumors complicating pregnancy are of rare occurrence. Risks of surgery and anesthesia during pregnancy are important not only for the mother but also for the fetus. The literature currently available is scarce to guide anesthetic management in neurosurgery for pregnant patients, thus making planning for such cases the most crucial step in patient care. Several important factors have to be considered when contemplating a surgical intervention during pregnancy including positioning, type of anesthetic, fetal heart rate monitoring, plans for urgent delivery, monitoring of maternal blood pressure, aspiration prophylaxis, and tocolysis for the prevention of preterm labor.[6],[7],[8] Anesthetic management should target on preventing hypoxemia, hypotension, acidosis, and hyperventilation. In our case, an arterial line was placed to quickly observe and treat hemodynamic changes. Maternal hypotension decreases uterine blood flow and can lead to fetal hypoxia. Steep alterations in maternal baseline blood pressure must be avoided to maintain adequate uterine blood flow. In addition, hourly urine output should be monitored.[4],[6],[9]

With regard to the post-COVID recovery setting, at the time of undergoing the present neurosurgical procedure, there were no definitive guidelines regarding the optimum gap in the recovery phase before undertaking elective neurosurgical procedures. However, recent guidelines provided in the joint statement on elective surgery and anesthesia for patients after COVID-19 infection formulated by the American Society of Anesthesiologists and Anesthesia Patient Safety Foundation state that a delay of 4 weeks is essential following asymptomatic or mild COVID infection after which elective surgery may be considered.[5] In retrospect, these guidelines have prompted us to consider a longer period of delay for taking up the case and would be a consideration for us in similar scenarios arising in the future.

During the spinal surgery, in the prone position, the placental perfusion may increase in pregnant patients. Nevertheless, difficulties such as fetal monitoring and increased epidural venous bleeding may be encountered. Additional care has to be taken for the position of the pregnant woman during surgery for excessive pressure can cause preterm delivery.[10],[11] The key factor in the management of such cases is to take meticulous care during positioning to ensure that the abdomen is free, no matter what position or operating table is chosen.

Pregnant women presenting for nonobstetric surgery represent a unique clinical situation where the health of the mother is paramount but equally careful consideration is needed for fetal well-being. A multidisciplinary team involving surgeons, anesthesiologists, obstetricians, neonatologists, and intensivists should be involved in the decision on proceeding with surgery. If the fetus is determined to be nonviable, i.e., during the first and early second trimesters, neurosurgical intervention should be undertaken as soon as possible to improve neurological outcomes with special considerations for surgery in pregnant patients.


  Conclusion Top


The requirement for neurosurgery during pregnancy is of rare occurrence. When such patients present to us, caring for such patients is likely to be challenging. A multidisciplinary approach is ideal in such a scenario to arrive at the best possible course of treatment for the well-being of both the mother and the fetus.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sutton LN, Phillips PC, Molloy PT. Surgical management of medulloblastoma. J Neurooncol 1996;29:9-21.  Back to cited text no. 1
    
2.
Sala F, Bricolo A, Faccioli F, Lanteri P, Gerosa M. Surgery for intramedullary spinal cord tumors: The role of intraoperative (neurophysiological) monitoring. Eur Spine J 2007;16 Suppl 2:S130-9.  Back to cited text no. 2
    
3.
Rahman A. Medulloblastoma. In: Agrawal A, Moscote-Salazar LR, editors. Brain Tumors – An Update. 1st ed. London, United Kingdom: Intech Open; 2018. p. 135-68.  Back to cited text no. 3
    
4.
Kazemi P, Villar G, Flexman AM. Anesthetic management of neurosurgical procedures during pregnancy: A case series. J Neurosurg Anesthesiol 2014;26:234-40.  Back to cited text no. 4
    
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Moletta L, Pierobon ES, Capovilla G, Costantini M, Salvador R, Merigliano S, et al. International guidelines and recommendations for surgery during Covid-19 pandemic: A systematic review. Int J Surg 2020;79:180-8.  Back to cited text no. 5
    
6.
Marulasiddappa V, Raghavendra B, Nethra H. Anaesthetic management of a pregnant patient with intracranial space occupying lesion for craniotomy. Indian J Anaesth 2014;58:739-41.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Nowicki RW. Anaesthesia for major spinal surgery. Contin Educ Anaesth Crit Care Pain 2014;14:147-52.  Back to cited text no. 7
    
8.
Deiner S, Silverstein J. Anesthesia for patients with spinal cord tumors. In: Farag E, editor. Anesthesia for Spine Surgery. Cambridge: Cambridge University Press; 2012. p. 247-56.  Back to cited text no. 8
    
9.
Care C, Access O. Anaesthesia for spinal tumor in the pregnant patient: A case report. J Anesth Crit Care Open Access 2017;8:8-9.  Back to cited text no. 9
    
10.
Bharti N, Kashyap L, Mohan VK. Anesthetic management of a parturient with cerebellopontine-angle meningioma. Int J Obstet Anesth 2002;11:219-21.  Back to cited text no. 10
    
11.
Öğrenci A, Akar E, Koban O, Işık S, Şener M, Yılmaz M, et al. Spinal anesthesia in surgical treatment of lumbar spine tumors. Clin Neurol Neurosurg 2020;196:106023.  Back to cited text no. 11
    


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