C-section on patient with secondary paraplegia resulting from spontaneous spinal epidural hematoma and acquired FXIII deficiency. A case report

Background: Spontaneous spinal epidural hematoma (SSEH) in a pregnant patient is an extremely rare clinical condition and requires emergency surgical evacuation, while termination of pregnancy depends on fetal viability status¹ . Etiology includes hemorrhagic diathesis, autoimmune inflammatory vasculitis, anticoagulant therapy, vascular malformations, and tumors. Pregnancy is considered a risk factor for SSEH. Below is a patient with SSEH and acquired FXIII deficiency (FXIII D) as a sole finding.

Case report: A 37 year old, gravida 3 para 2, 28 weeks of gestation was transferred to our hospital with symptoms of progressive paraplegia over 72 hours. MRI showed spinal lesion due to spontaneous epidural hematoma, emergency decompression followed with a T1-T5 laminectomy. A hemorrhagic episode required transfusions up to 4 RBCs and 2 FFPs during the laminectomy, neither FXIII nor Tranexamic acid (TXA) was given on that occasion. The neurological examination showed flaccid paraplegia, with sensitive level at T3. Test results showed normal values except in FXIII-A concentration 28% (60-160%). No other major bleeding cause could be determined aside from the FXIII D. Two months later, she had a c-section performed at 36 weeks of gestation. Intravenous plasma-derived FXIII (pdFXIII) concentrate 2500 IU was given preoperatively along with TXA 1g. General anesthesia using propofol for induction and sevorane for maintenance was administered, no muscle relaxants or opioids were necessary. Videolaryngoscopy was used for orotracheal intubation. Bleeding was between normal ranges. There was no need for RBC transfusions. A healthy female baby was born with a 8/9 Apgar score and 2,840 grams. Post-operative FXIII-A level was 69%.

Discussion: There are merely a few dozens of pregnant SSEH cases reported in the literature. Regional anesthesia for paraplegic condition is advised as the best technique to prevent autonomic dysreflexia; although general anesthesia seems more appropriate to prevent further spinal complications in patients with hemorrhagic diathesis² . References: 1. Krishnan P, et al. Neurol India. 2014;62(2):205-7. 2. Jones BP, et al. Can J Anaesth. 2000;47(11):1122-28.

Learning points: General anesthesia is an adequate anesthesia technique for paraplegic patients with FXIIID. FXIII should be tested even if coagulation test results are normal, and preoperative pdFXIII administration is probably the best way to prevent severe bleeding as well as TXA in these patients.