[Epidural bleeding after labor epidural analgesia]. / Saignement péridural suite à une analgésie péridurale obstétricale.

Anaesthetists often stand in the front line to manage postpartum neurological deficits, although epidural analgesia is rarely responsible for these complications. An epidural analgesia was performed to relieve pain during spontaneous labor in a 34-year-old parturient. An emergency C-section was subsequently required due to fetal heart rate abnormalities. Twelve hours after catheter removal, the parturient developed a severe right leg motor and sensory neurological deficit, predominant on L5 and S1 roots and diagnosed by a neurologist as a central nerve root injury. Lumbar MRI identified a non-compressive epidural bleeding in front of the L5 vertebral body. Epidural bleeding after labor epidural analgesia is a rare complication that may jeopardize the functional prognosis. It may be difficult in some cases to differentiate an upper plexus injury due to labor and delivery from a central epidural analgesia-related nerve root lesion. Fetal head compression at the pelvic brim may induce neurological deficits in several well-differentiated nervous territories, thus mimicking an anaesthetic-induced perimedullar radiculopathy.

Combined factor V and VIII deficiency and pregnancy--need for an early protocol-based multidisciplinary management.

We report the medical management of a 32-year-old primigravida, after she was found to have a combined factor V (FV) and factor VIII (FVIII) deficiency during pregnancy. A routine coagulation profile performed during the 6th month of pregnancy showed a prolonged activated partial thromboplastin time (aPTT) of 78 seconds, giving a patient/control ratio of 2.29, combined with a prothrombin time (PT) of 28 seconds. An investigation of the coagulation factors showed a combined FV and FVIII deficiency of 29% and 21% respectively. The bleeding risk was considered to be high. A multidisciplinary approach permitted a specific and individualized FVIII substitution protocol. At 39 weeks of amenorrhea, the patient was admitted to the labor room. An infusion of 2000IU of FVIII was implemented over 5 minutes; soon thereafter, PT was 17 seconds, aPTT patient/control ratio had decreased to 1.9 and FV and FVIII reached 38% and 36% respectively. Six hours later, the patient delivered an infant weighing 2850g who had an Apgar score of 10. No bleeding was detected. The patient was then closely monitored for 2 hours in the recovery room. Twelve hours after administration of the first dose of FVIII, another infusion of 2000IU of FVIII was administered. This substitution treatment was continued every 12 hours in ever-decreasing doses, allowing maintenance of FVIII level >50% for 5days. At D7 post-partum, the patient was discharged uneventfully.

[Bilateral carotid artery dissection in a severe preeclamptic setting: an unusual cause of postpartum headache]. / Dissection artérielle carotidienne bilatérale dans un contexte de prééclampsie sévère : une cause inhabituelle de céphalées du post-partum.

A 30-year-old woman with severe preeclampsia presented at 27 weeks of amenorrhea with left headache, neck pain, blurred vision and numbness of left hemiface that resolved spontaneously within 2 hours. A week later, hypertension remained poorly controlled despite combination of nicardipine and labetalol intravenous therapy; an urgent caesarean section was eventually performed due to onset of HELLP syndrome. At day 5 postpartum, the patient had a Horner syndrome with right ipsilateral disabling tinnitus. A CT-angiography of supra-aortic trunks was performed urgently; it showed a bilateral carotid arterial dissection without stroke, which was subsequently confirmed by MRI angiography. The patient was transferred in neurovascular intensive care unit. Anticoagulant therapy was implemented to prevent cerebral and retinal ischemic lesions. Symptoms resolved quickly and the patient was discharged at day 7 postpartum. MR-angiography performed 4 months later showed a full resolution of the bilateral carotid dissection. Anticoagulant therapy was therefore discontinued.