How would you handle this OB case?

[ReefTiger]

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I had an interesting case tonight.

32 y/o spanish speaking only with term IUP in labor with baby showing variable decelerations. OB's chomping to go to c/s.

Mother ~68kg, good airway, no spine issues and overall in excellent health
except she has had subdural hematomas (cranial) requiring bilateral burr holes, a visit to the ER for a percutaneous draining and neurosurgery involvement a third time for placement of a left sided drain (since removed). Last issue with the subdural was in July. Onset of subdural occurred during this pregnancy. She states no physicians have diagnosed cause.

Hb 10.4, platelets 225, last food 10 hrs prior.

How do you proceed? I'll let you guys reply and then I'll tell you how we did the case.

 

[VentdependenT]

Von willibrans vs C/S deficiency. She needs a work up regardless for her subdurals if they aint related to trauma.

Otherwise Epidural.

 

[toughlife]

I had an interesting case tonight.

32 y/o spanish speaking only with term IUP in labor with baby showing variable decelerations. OB's chomping to go to c/s.

Mother ~68kg, good airway, no spine issues and overall in excellent health
except she has had subdural hematomas (cranial) requiring bilateral burr holes, a visit to the ER for a percutaneous draining and neurosurgery involvement a third time for placement of a left sided drain (since removed). Last issue with the subdural was in July. Onset of subdural occurred during this pregnancy. She states no physicians have diagnosed cause.

Hb 10.4, platelets 225, last food 10 hrs prior.

How do you proceed? I'll let you guys reply and then I'll tell you how we did the case.

Any more info re: coags?
I had a patient on coumadin who had a spontaneous spinal hematoma.Is this pt on any anticoagulants?

 

[militarymd]

non-traumatic subdural hematomas are either related to a coagulopathy or anatomic abnormality...

without lab work and imaging studies, you have no way of knowing the origins of these hematomas....

If you can rule out a coagulopathy quickly....and there are no issues with impending herniation....then you can do a regional technique....SAB....and NO, she is not going to herniate because you put a tiny hole in her dura.

Otherwise, put her to sleep.

 

[Noyac]

Without knowing the coag's I'd lean towards putting her to sleep. If she does not have any other signs of coagulopathy like bleeding gums after brushing teeth, petechia, bruising,etc. Then I'd have to really consider a SAB. No epidural. I hate epidurals for c/s personally. I'd personally, try to talk the OB into waiting a few minutes to get coag's if the baby is stable. Variable decel's can wait depending on their severity.

The herniation come from increased ICP and a big hole in the dural. Very very unlikely here.

Good case. I'm interested to hear what the coag's were and what you did.

 

[Laryngospasm]

I had an interesting case tonight.

32 y/o spanish speaking only with term IUP in labor with baby showing variable decelerations. OB's chomping to go to c/s.

Mother ~68kg, good airway, no spine issues and overall in excellent health
except she has had subdural hematomas (cranial) requiring bilateral burr holes, a visit to the ER for a percutaneous draining and neurosurgery involvement a third time for placement of a left sided drain (since removed). Last issue with the subdural was in July. Onset of subdural occurred during this pregnancy. She states no physicians have diagnosed cause.

Hb 10.4, platelets 225, last food 10 hrs prior.

How do you proceed? I'll let you guys reply and then I'll tell you how we did the case.

Put her to sleep, I dont know about your lab, but the kid could be brain dead before we would get any lab results back. Have some blood products ready. Obviously depending on the severity of the decels.

EDIT: also the fact that other physicians have been trying to solve this for several months, tells me that coags probably wont tell you much.

 

[seattledoc]

I'd go with GA.
subdural bleed of unknown cause...I'd be nervous to needle that.

 

[Noyac]

I'd go with GA.
subdural bleed of unknown cause...I'd be nervous to needle that.

She could get pretty hypertensive with the typical academic c/s induction which would just as easily rupture another vessel.

 

[LostTommyGuns]

I find it interested that no one diagnosed the cause. More information on the workup would be useful - if they just ran Coags and they were normal that's one thing but if they gave her the whole gambit and nothing turned up I would be pretty fearful of the Epidural.

Then again, it's not like a C/S is a bloodless procedure and if the Ob's aren't worried then perhaps that lends credibility to me not worrying... I'll say that I'd like to know more about her work-up so that I may more seriously consider an epidural, but if we have to roll back now then GA.

Good case.

 

[aredoubleyou]

I find it interested that no one diagnosed the cause. More information on the workup would be useful - if they just ran Coags and they were normal that's one thing but if they gave her the whole gambit and nothing turned up I would be pretty fearful of the Epidural.

Then again, it's not like a C/S is a bloodless procedure and if the Ob's aren't worried then perhaps that lends credibility to me not worrying... I'll say that I'd like to know more about her work-up so that I may more seriously consider an epidural, but if we have to roll back now then GA.

Good case.

OB's not worried doesn't relieve any of my anxiety. Ive experienced the attitude (by some -not all) that everything above the hip is somebody elses job.

 

[LostTommyGuns]

OB's not worried doesn't relieve any of my anxiety. Ive experienced the attitude (by some -not all) that everything above the hip is somebody elses job.

I agree, just because someone else doesn't see a potential problem doesn't mean that i don't. However I may weigh it differently having more than one opinion. Really what I was getting at is that if they are not worried, perhaps there is a reason. Is it possible that they know more than me? Are there tests that were run that I don't know about? For a surgeon doing a potentially bloody surgery to not be worried about 3 separate subdurals means they either know something I don't, I know something they don't, or they're just ballsy as heck. Either way, my feeling is that I would really like more info.

 

[Laryngospasm]

For a surgeon doing a potentially bloody surgery to not be worried about 3 separate subdurals means they either know something I don't, I know something they don't, or they're just ballsy as heck. Either way, my feeling is that I would really like more info.

Dont forget stupid and careless, they are in every profession, even medicine.

 

[ReefTiger]

Sorry about the delay in my reply.

The OB's were concerned about both the unknown etiology and fetal distress. Since there were no coags and little time we elected to do GA. There was no point in risking any complications from regional when I was 99%sure we could easily intubate her. We used thipental induction and sux. Case went smoothly.

 

[Noyac]

Sorry about the delay in my reply.

The OB's were concerned about both the unknown etiology and fetal distress. Since there were no coags and little time we elected to do GA. There was no point in risking any complications from regional when I was 99%sure we could easily intubate her. We used thipental induction and sux. Case went smoothly.

So what was the dx?

 

[ReefTiger]

We don't have an etiology/diagnosis for the subdurals. As anesthesiologists we aren't the primary team. The OB's got their baby, so I don't think they'll pursue this any further.