Expert: Dr Ian Jackson - please note UK based - 1/2/2010

Question
QUESTION: hello,at the age 30 having blood group AB-ve i went to labour in 36 week......my gyne told me to take epidural ....at that day when i asked them to give me epidural they declined telling me that you cant have,my blood platelet count was in the lower side but within normal ranges...CTG normal...vitals normal at that day,they took vaginal culture test and injected an antibiotic after test dose.Then a c-section took place under G.A ,at 2.45 baby born and at 5.30 i opened my eyes and after gaining consciousness i found that my whole body was swollen.My questions are;

1)what are the conditions in which epidural is not given or advise and are there any tests to determine that?
2)why was i swollen was there an allergic reaction to general anaesthesia and usually how long it takes to settle down.
3)how long it usually takes to gain consciousness after having G.A and why it took me so long to do so what could be the reason.



ANSWER: Kiran
I will answer what I can
1. Epidurals are contraindicated if you have a low platelet count as there is a risk of causing bleeding inside your spinal column leading to a spinal blood clot that can be serious as it puts pressure on your spinal cord.
They are also contraindicated if you have been on agents to 'thin' your blood, if you have an infection in the skin where the epidural needs to be sited or for several other specialised reasons.
2. I can't really say why you were swollen except that if your platelets were low then perhaps they were concerned you had an illness called pre-eclampsia. This affects your kidneys and blood vessels and can cause swelling.
3. How long it takes to wake up depends on the amount of anaesthetic you have been given, the type of agent used and your sensitivity to the agent. However waking up time also depends on when the operation ended - not when the baby was born so that will play a part as well.

Hope the above helps a bit - it is difficult to give concrete information without seeing your notes etc - I can only give possibilities.
Kind regards
Dr Ian Jackson

---------- FOLLOW-UP ----------

QUESTION: Thanks for your help and reply,wanted to give detail and hope after that you can give concrete information.
1)EPIDURALS........
a week before my c-section my platelet count was 398x10E9/L range(150-400).i didn't have any skin infection and was not using any blood thining agents,i used low dose Aspirin75mg ,syp Mucaine,Tab Zantac(ranitidine)from 30-33 week after that no medication at all.before 30 week i had super condition it was in 30 week i had vomit and heart burn .

QUESTION.1....can you now suggest why they refused to give epidural  where can i find all contraindications listed for epidural.

2)ABOUT GENERALISED BODY SWELLING..
from7-30week B.P was in ranges of 110-120/70-80,30week130/90
,32week130/80,33week120/80,35week130/80,at LABOUR DAY 37week 120/80...

QUESTION 2.....was i suffering from pre-eclampsia.?

other tests LDH 292 I.U/L(220-541),S.URIC ACID 4.1 mg/dl(2.4-7.2),URINE DETAIL REPORT CLEAR ALL NEGATIVE AND NIL,GCT 159 mg/dl.....gestational diabetes.At 33 week i developed swelling of knee and feet only.............unlike my c-section after which my whole body had swelling.

QUESTION 3)was the generalised body swelling due to general or patient controlled anaesthesia or else?

still after 15months of delivery i suffer from pain in thoracic,lumbar and sacral region.both knee swelling but more in right one with muscle stretch in around area of knee and pain in right ankle.

QUESTION 4)Are these complications due to anaesthesia or they did some damage to my nerves during surgery,how can i find out?

3)TIME FOR GAINING CONSCIOUSNESS AFTER G.A..... at 2.45 baby born and after half hour by 3.15 surgery ended and gain consciousness at 5.30 ,it was 45 min surgery.

QUESTION5....now can you tell me why it took me so long(2hour and 15 min )to gain consciousness?
         THANKS IN ADVANCE
         KIRAN

Answer
Kiran
You don't say what your platelet count was on the day of your delivery but there is no contraindication for epidural if it is above 100 - which it sounds like yours was. We have covered most of the contraindications already but list can be found at http://www.nda.ox.ac.uk/wfsa/html/u13/u1311_01.htm#cont
To these (in the UK) we would add - lack of experience of staff looking after patient i.e. we wouldn't perform an epidural unless there were sufficient numbers trained staff to look after you.
So I can't really guess why they denied you an epidural - however given your problems if you had succeeded in getting one you would be asking me did it cause your back pain.

The BP's and results you mention don't fit with pre eclampsia

Generalised swelling - apart from pre-eclampsia the only time I have seen generalised swelling has been as part of a reaction to a drug given to the patient. That could include all drugs given not just the general anaesthetic agents - so antibiotics, syntocinon are all possible contributers. It might be that you have a sensitivity to one of the drugs used or even to something that someone was wearing - in the UK we are seeing a large increase in patients who are sensitive to latex gloves.

I'm afraid that pregnancy puts a large strain on your body with the hormones (esp progestogen) causing your ligaments to become soft and lax. This plus all the lifting after childbirth often leads to mothers having back problems. You cannot attribute these symptoms to the anaesthesia and they don't go near your back nerves for a c-section. Patients who have been in prolonged labour sometimes develop problems due to the pressure of the babies head on the nerves in their pelvis but this is normallly a short lived problem and doesn't involve the pain distribution you mention. Hence I stick with my thoughts on this being linked to the pregnancy and the strain on your body.

You took a long time to wake up - this happens and none of the info you have provided gives me any clues as to why. Have the doctors involved not given an explanation for the swelling and slow wake up time? Was their a link? Were they sorting out some sensitivity problem before waking you up?  I'm sorry but I don't have any answer for this.
Can I end by saying that in my experience it is important to sit down with those involved and go through why things happened the way they did. Second guessing by other doctors doesn't really help as we don't have all the facts before us.
I wish you health in 2010.
Dr Ian Jackson