Horner's syndrome with epidural anaesthesia

Abstract

A 29-year-old woman, primigravida, had labour induced for post-maturity following an uncomplicated antenatal course. She requested an epidural prior to commencement of syntocinon. This was administered in the sitting position without complication. The midwife noted drooping of the right eyelid of the patient 6.5 h following insertion of the epidural. Blood pressure and CTG remained reassuring. The obstetric anaesthetist reviewed the labouring woman and noted a right-sided ptosis as well as the right cheek being flushed and dry. There was no motor block and sensation in T1/T2/S3/S4 was intact. Horner's syndrome was diagnosed and anaesthetic review was recommended prior to further top-ups. The patient progressed well in the second stage of labour and did not require further top-ups and gave birth to a healthy male infant. Horner's syndrome resolved within 4 h following delivery and the postpartum period was uncomplicated.

Horner’s syndrome and epidural anesthesia in labor and cesarean section

“…The typical symptoms usually occur unilaterally, in some cases bilateral in 11.5% [29]. The reasons are the following: slow injection of small volumes, pregnant positioning, baricity of local anesthetic, congenital transverse septum in the epidural space, and tip of the epidural catheter [23,30]. The most commonly HS associated symptoms include nasal stuffiness, blurry vision, strange feeling of the eye, and maternal hypotension dyspnea depending on interruption of the symphathetic chain of neurons at C8-T1.…”

“…There is no HS case reported during the Valsalva manoeuvre during labor, although there is an increased risk of stroke from paradoxical emboli. HS is not associated to hypotension that could lead to side effects concerning both the mother and the embryo [23]. HS cases subsequent to carotid dissection, which occurs in a variety of incidents like minor trauma, sneezing, and coughing was rarely reported [24].…”

Síndrome de Horner durante anestesia neuroaxial en anestesia obstétrica – revisión de la literatura

“…No obstante, dado el espectro de severidad de los síntomas de esta entidad, se cree que hay un subregistro epidemiológico de los casos pues la mayoría de pacientes son asintomáticas [13] o los cambios sutiles clínicos pueden haber sido ignorados durante su presentación. Por ejemplo, en un estudio prospectivo se demostró una incidencia de 75% de síndrome de Horner en embarazadas que reciben anestesia epidural [14] cuando específicamente se exploraba por cambios pupilares u otras manifestaciones de bloqueo simpático cervical [15]. En este mismo estudio la anestesia caudal se asoció con una incidencia mayor de síndrome de Horner, reportada como de 55% [1].…”

“…El síndrome de Horner se origina de un bloqueo de las fibras simpáticas altas (C8-T1) a nivel central o periférico 16 . La mayoría de veces es unilateral y se adquiere por una patología subyacente; sin embargo, su etiología puede ser congénita o iatrogénica [14]. Clínicamente se presenta con ptosis y miosis por parálisis del músculo de Müller y dilatador del iris respectivamente, enoftalmos por efecto visual de la ptosis, anhidrosis por denervación de las fibras simpáticas y enrojecimiento facial por pérdida del control vasomotor [16].…”

“…otros, la continuación de la anestesia es posible; lo más importante será la vigilancia estricta, y en caso de sospechar paro respiratorio será prudente interrumpir el anestésico y elegir otra alternativa como analgesia[14]. De esta manera, el manejo es totalmente individual.…”