Year : 2022 | Volume
: 12 | Issue : 2 | Page : 161--163
Anaesthetic management of a parturient with juvenile parkinson's disease in emergency – A case report
Aravind Ramalingam, Divya Devanathan, Rani Ponnusamy
Department of Anaesthesiology, Mahatma Gandhi Medical College, Sri Balaji Vidyapeeth University, Pondicherry, India
Dr. Divya Devanathan
Assistant Professor, Department of Anaesthesiology, Mahatma Gandhi Medical College, Sri Balaji Vidyapeeth University, Pondicherry - 607 402
The association of Parkinson's disease and pregnancy is very rare. We present a case of juvenile Parkinson's disease patient who underwent emergency caesarean section. The anaesthetic considerations and management are discussed.
|How to cite this article:|
Ramalingam A, Devanathan D, Ponnusamy R. Anaesthetic management of a parturient with juvenile parkinson's disease in emergency – A case report.J Obstet Anaesth Crit Care 2022;12:161-163
|How to cite this URL:|
Ramalingam A, Devanathan D, Ponnusamy R. Anaesthetic management of a parturient with juvenile parkinson's disease in emergency – A case report. J Obstet Anaesth Crit Care [serial online] 2022 [cited 2022 Nov 27 ];12:161-163
Available from: https://www.joacc.com/text.asp?2022/12/2/161/355358
Juvenile-onset Parkinson's disease (PD) occurs before 21 years of age and several genetic mutations are identified as the cause. Seier et al. reviewed 28 papers published in English, ranging from 1985 to 2016, in which reports of pregnancy and PD were discussed. These papers yielded a total of only 74 live births that happened to women with PD who were 23–46 years old. Anaesthetic management of PD is complicated by the fact that many drugs used in the treatment have significant interaction with anaesthetic agents that can have profound anaesthetic implications in the pregnant patient.
Thus, Pregnancy in PD is a rare occurrence, and to date, clinical experience with its management is rather limited.
A 26-year-old, 39-week primigravida presented for emergency caesarean section with indication as fetal distress. Her medical history included PD, which was diagnosed at the age of 10 years. It started as febrile illness and later developed generalised tremor and difficulty in walking. Computed tomography (CT) brain showed loss of normal swallow tail appearance of susceptibility signal pattern in substantia nigra. She was treated with tab. levodopa/carbidopa 100/15 mg half tablet ter die sumendum (TDS), tab. trihexyphenidyl 6 mg/day, and tab. propranolol 40 mg once daily (OD) and the patient had adequate symptom control with the above medications.
She had a spontaneous conception. In the first trimester, she had hyperemesis, which was managed conservatively. There was no exacerbation of Parkinson's symptoms in the first and second trimesters. Second trimester anomaly scan was normal. Tab. propranolol was stopped at 32 weeks of gestation. Neurological examination revealed a normal sensory system. Resting tremors were present. Rigidity was present in all four limbs, more in upper limbs. Gait was not examined. She had generalised tremor involving the entire body during each uterine contraction, which subsided with the end of contraction.
After confirmation of intake of morning medication for PD, spinal anaesthesia was planned after getting consent from her. She received inj. ranitidine 50 mg and inj. ondansetron 4 mg as premedication. Spinal anaesthesia was performed with the patient in sitting position with 1.8 ml of 0.5% hyperbaric bupivacaine and 25 μg fentanyl. Left uterine displacement was performed. Lower segment caesarean section was performed after adequate sensory block to cold at T4 had been achieved. The generalised tremors which were present earlier subsided after giving spinal anaesthesia. There were episodes of hypotension, which were managed effectively by intravenous (IV) fluids and boluses of phenylephrine. The patient was sedated, but arousable and able to receive her baby soon after delivery.
Her postoperative course was uneventful and there was no exacerbation of Parkinson's symptoms. Her routine anti-Parkinson's medications were continued in the postoperative period after consultation with her neuro-physician. She was discharged on postoperative day 5 uneventfully.
PD is an age-related disease; thus, women with PD presenting with pregnancy are very uncommon. The course of PD in Pregnancy is also varied. Earlier, Olivola et al. found that studies done on the impact of pregnancy on PD described no change, improvement or worsening of the motor symptoms. In some cases, worsening of non-motor symptoms was also observed. In our case, the patient had no worsening of either motor or non-motor symptoms during pregnancy.
The anaesthetic concerns in managing pregnancy associated with PD are as follows:
Sudden exaggerated and uncertain response to subarachnoid block or anaesthetic drugs caused by autonomic dysfunctionRisk of perioperative aspiration pneumonia due to increased retention and impaired expulsion of respiratory secretions caused by pharyngeal muscle weaknessDrug-induced nausea, vomiting, increased gastric stasis and GERDPsychotic symptoms like delusion and hallucination caused due to drug side effects can be confused with postoperative emergence reactions, leading to dilemma at the time of extubationDrug interactions:
Levodopa can cause nausea, vomiting, dehydration and hypovolemia. Through central mechanisms, it can cause hypotensive effects. Hence, patients might require adequate pre-op fluid resuscitation.Dopamine agonists precipitate hypotension by peripheral vasodilation.
Thus, patients with PD require preoperative optimisation including drug dose adjustments prior to an elective surgery.
The choice of anaesthesia is challenging in obstetric patients with PD. While general anaesthesia has the advantage of having a still patient, it predisposes to risk of aspiration as the patient may have pharyngeal muscle weakness. Opioids can cause muscular rigidity and acute dystonia. Chest wall rigidity caused by opioids might interfere with ventilation leading to postoperative chest infection, which is further worsened by difficulty in clearing secretions, ineffective cough and impaired swallowing. Further use of opioids in postoperative pain relief can cause nausea, vomiting and sedation, which can further exacerbate the risk of aspiration. Residual neuromuscular block might delay the diagnosis and treatment of exacerbation of PD symptoms.
Regional anaesthesia has obvious advantages over general anaesthesia in PD. Spinal anaesthesia allows communication with the patient and provides a better pain relief, reducing the surgical stress response. The risk of postoperative nausea and vomiting is less, allowing the patient to take his/her regular oral medications. However, tremors present in areas not covered by anaesthesia might interfere with monitoring of the patients. Though our patient presented with generalised tremor during uterine contraction, tremors subsided in between contractions. Hence, spinal anaesthesia was planned for her and performed during the tremor-free period. Post-spinal, our patient was comfortable, tremor free and communicating.
Patient had episodes of hypotension in the intraoperative period probably due to autonomic dysfunction caused by PD or may be levodopa induced and were managed with IV fluids and phenylephrine boluses. There were no other intraoperative complications during surgery and the rest of the surgery was uneventful.
During the postoperative period, the patient became ambulant on day 1, was feeding her child; no worsening of Parkinson's symptoms was noted and she was discharged on postoperative day 5.
We present this case in view of a rare presentation of a parturient with PD for emergency caesarean section. In these cases, we recommend the use of spinal anaesthesia with adequate monitoring for hypotensive episodes. However, further studies need to be conducted in this regard.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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