Lower section cesarean section (LSCS) is the most commonly performed surgery today
and spinal anesthesia is the preferred mode of anesthesia in most of the cases. Headache
occurring during cesarean section (LSCS) can have many causes like stress or anxiety,
post-dural puncture headache, hypotension, etc. We report a case of patient developing
headache and left side weakness intraoperatively, which on further investigation found
to be due to development of intracerebral hemorrhage (ICH).
A 34 years old American Society of Anesthesiologists grade II primigravida with twin
pregnancy was admitted for an elective cesarean section. She was a booked patient
and had an uneventful pregnancy. Her baseline heart rate inside the operation theater
was 89 beats per minute and blood pressure was 116/74 mm Hg in supine position. All
her blood investigations were within normal limits. She was administered 2.2 mL of
injection bupivacaine (heavy) in lateral decubitus position using a 25 G Quinke's
spinal needle in the first attempt. The intraoperative monitoring included continuous
electrocardiography, oxygen saturation monitoring, and noninvasive blood pressure
monitoring every 5 minutes. Two healthy female infants were delivered and she was
administered 5 units of oxytocin intravenously. Around 20 minutes after delivery of
the twins, the patient started complaining of severe headache. She was administered
1 g of intravenous paracetamol for control of headache; however, her headache was
not relieved. Toward the end of surgery, the operating surgeon felt that the face
of the patient was deviated toward the left side and she was still complaining of
severe headache. On further examination, it was found that she was having difficulty
in moving her left upper limb. At the end of surgery, her Glasgow Coma Scale (GCS)
score was E4V4M5, and both pupils were equal and reactive to light. Throughout this
period, there was no documented systolic blood pressure reading of over 150 mm Hg.
On the basis of these findings, a decision was taken to perform an urgent noncontrast
computed tomography (CT) scan head in this patient, which revealed right basal ganglia
bleed with intraventricular bleed ([Fig. 1]). A neurosurgery consultation was taken and they advised CT angiography of cerebral
vessels. CT angiography did not show any evidence of arteriovenous malformation (AVM)
or a cerebral aneurysm in the patient. On the basis of investigation findings, a decision
to perform decompressive craniectomy was taken. Her perioperative course was uneventful.
She was kept intubated and sedated overnight and was extubated the next day. She was
shifted to ward after 2 days of extubation and discharged to home 10 days after surgery.
At the time of discharge, her GCS was E4V5M6 and her motor power was ⅖ in the upper
limb and ⅗ in the lower limb.
Fig. 1 Non-contrast CT head of the patient demonstrating right basal ganglia bleed with
intraventricular extension.
ICH during pregnancy is a rare but catastrophic event. The incidence of stroke in
pregnancy is 9 to 26 per 100,000 pregnancies; hemorrhagic strokes account to approximately
38% of the total strokes.[1] AVMs are the chief cause of ICH in pregnancy.[2] Other causes of ICH in pregnancy include cerebral aneurysms, cerebral venous thrombosis,
trauma, pregnancy-induced hypertension, and coagulopathies.[3]
Development of ICH after cesarean section is even more rare, with only two reports
available in literature.[4]
[5] Sharma reported development of symptoms of ICH in a post-LSCS patient 4 hours after
the surgery, while in a report by von Knobelsdorff and Paris, the symptoms of ICH
developed 80 minutes after the LSCS.[4]
[5] To our knowledge, this is the first report to demonstrate occurrence of symptoms
of ICH intraoperatively. Dai and Diamond had reported development of spontaneous ICH
in a pregnant female with pregnancy-induced hypertension.[6] They described advanced maternal age (in particular, age older than 35 years); African
American race; preexisting hypertension (chronic hypertension), gestational hypertension,
preeclampsia (or eclampsia), preexisting hypertension with superimposed preeclampsia/eclampsia,
or coagulopathy; and tobacco abuse/dependence as risk factors for development of ICH.
However, our patient did not have any of these predisposing factors for development
of ICH. There was no history of preeclampsia in our patient and she had regular routine
checkups during the pregnancy. Although variations in blood pressure are common during
cesarean section, there was no documented systolic blood pressure reading of more
than 150 mm Hg in our patient intraoperatively. However, noninvasive blood pressure
monitoring has its limitations and is not able to document sudden surges in blood
pressure. Also, the location of bleed in our patient points toward it being a hypertensive
bleed. ICH after cesarean section is a rare but possible complication. A high index
of suspicion should be there for any severe headache and newly developed motor deficit
developing intraoperatively to diagnose ICH at the earliest.
