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Chapter 62: Peripartum Neurological Complications

Maria C. Borrelli; Philip E. Hess

INTRODUCTION

Most nerve injury after childbirth can be attributed to delivery of the neonate. These are referred to as intrinsic obstetric palsies, and are often due to stretching or compression of the lumbosacral plexus and lower extremity peripheral nerves. Fortunately, obstetric palsies are usually transient with expected full recovery. Rarely, potentially catastrophic neurological complications occur after neuraxial procedures. Prompt recognition and treatment are essential to avoid permanent injury.1-3 Diagnosis and differential diagnosis of peripartum neurological injury are summarized in Fig. 62-1.

FIGURE 62-1

Diagnosis of peripartum neurological injury. EBP, epidural blood patch; IV, intravenous; PDPH, postdural puncture headache; Stat MRI, emergent magnetic resonance imaging.

A flowchart shows the process of diagnosis of peripartum neurological injury. The flowchart is titled, ‘Neurological complications of neuraxial anesthesia.’ The data given in the flowchart is as follows: Patient assessment: Vital signs, Physical exam, Medication regimen. 1, If the pain is experienced as a headache by the patient and it is positional, examine the altered mental status and the focal neurological signs. Suspect PDPH and finally consider EBP. If the pain is experienced as a headache by the patient and it is non-positional, it leads to three sections. The first section asks to examine the altered mental status and the focal neurological signs; Suspect the subdural hematoma and finally Stat MRI. The second section asks to examine the altered mental status of fever, Kernig, and Brudzinski; Suspect meningitis, and finally Stat ID consult, IV antibiotics. The third section asks to check if the patient has hypertension and then suspect preeclampsia. 2, If the pain is experienced as muscle soreness by the patient: If the pain worsens with activity and is reproducible, suspect muscle pain. Finally, monitor conservative treatment. If the pain is experienced as muscle soreness by the patient and if it is mild back pain: If the pain worsens with activity and is reproducible, suspect muscle pain. Finally, monitor conservative treatment. If the pain is experienced as muscle soreness by the patient and if it is mild back pain: If the patient experiences weakness, numbness, and paresthesias, suspect catastrophic central lesion and finally stat MRI neurosurgery consult. 3, If the pain is experienced as back pain by the patient and if the pain is severe: If the patient experiences weakness, numbness, and paresthesias, suspect catastrophic central lesion and finally stat MRI neurosurgery consult. If the patient experiences coagulopathy, skin changes at the time, bowel or bladder incontinence, suspect catastrophic central lesion. Finally, stat MRI neurosurgery consult.
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MILD COMPLICATIONS—MUSCULAR STRAIN

Myofascial pain syndrome: may occur in any region (common in neck, shoulders, lower extremities):

  • Muscle hypertonicity/edema with marked tenderness at specific anatomic points

  • Cervical myofascial pain, base of occiput, and neck pain without positional changes

  • Management: Acetaminophen/Nonsteroidal anti-inflammatory drugs (NSAIDs), ice/heat, physical therapy (PT) consult

MODERATE COMPLICATIONS—PERIPHERAL NERVE INJURIES (TABLE 62-1)

  • Associated with prolonged first or second stage of labor, difficult instrumental delivery, nulliparity, extremes of stature, and prolonged use of the lithotomy position

  • Unilateral, with weakness/paralysis in single muscle or group of muscles

  • Unilateral sensory deficits in nerve distribution

  • May be bilateral, especially with plexus injuries

  • Management: Conservative, consult PT with presence of muscle weakness

TABLE 62-1Characteristics of Peripheral Nerve Injury
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TABLE 62-1 Characteristics of Peripheral Nerve Injury

Nerve Palsy

Symptoms

Possible Etiologies

Lumbar plexus

Knee extension weakness, anterior thigh sensory deficit, can have saphenous nerve deficit, may be associated with hip flexion weakness and hydronephrosis

Cephalopelvic disproportion, prolonged labor, and difficult vaginal delivery

Sacral plexus

Sciatic distribution sensory deficit and weakness, foot drop

Compression of the plexus between the bony pelvis and fetal presenting part

Obturator

Weakness of hip adduction/internal rotation, sensory disturbance over medial thigh

Compression of the nerve between pelvis and fetal head, forceps delivery

Femoral

Weakness of hip flexion, patellar reflex is diminished/absent; sensory deficit of anterior thigh and medial calf

Stretch intrapelvic portion in lithotomy position or compress the nerve under the inguinal ligament or in the posterior iliopsoas region

Lateral femoral cutaneous (meralgia paresthetica)

Numbness, tingling, or burning sensation of the anterolateral aspect of the thigh

Entrapment of the nerve under the inguinal ligament by gravid uterus, retractors, obesity, or prolonged lithotomy position

Sciatic

Weakness and decreased sensation below the knee with sparing of the medial leg

Compression of nerve in buttock (piriformis) or posterior internal pelvis, stretch injury due to lithotomy position, prolonged sitting on a misplaced wedge

Peroneal (fibular)

Footdrop/weak ankle eversion, sensory deficit on the anterolateral calf and dorsum of the foot

Excessive knee flexion, compression of the lateral side of the knee, prolonged use of the ...

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