Case presentation

Thirty-year-old, G2P1 presented to triage at 36 weeks of gestation with complaints of severe backpain, headache with progressive oedema and weakness of both lower limbs. Neurological examination showed sensory loss to cold and touch up to L1, motor power of 1/5 in both lower limbs. Rest of the neurological examination was unremarkable. Abdomen was tense with large transverse scar. CTG was normal.

Patient had history of bariatric surgery four years ago followed by abdominoplasty and aesthetic surgeries in both arms and legs , also known to have depression and history of multiple DNA’s for present pregnancy.

Urgent MRI brain and spine depicted crowding of cauda equina at L4-S1 and CSF space effacement due to anterior venous plexus engorgement. CT showed engorgement of pelvic vessels with no major abdominopelvic vessel thrombosis.

Extensive discussion between obstetric, anaesthetic, neurology and neurosurgical team decided for no neurosurgical intervention. An MDT decision was made to perform emergency caesarean section the following day. Patient had an uneventful general anaesthetic. Surgery was challenging due to tough abdominal wall and crowding of space. Her symptoms improved significantly after delivery resulting in full recovery on second post op day. MDT discussion opined engorged anterior venous plexus in epidural space secondary to pelvic venous congestion caused by gravid uterus and limited stretching of anterior abdominal wall resulting in neurological signs and symptoms .

Timeline

Sudden onset of Paraparesis and loss of sensation to cold and touch on both lower limbs

MRI Spine- No neurosurgical cause requiring intervention

MRI Spine Sagittal/Axial-dEngorged venous plexus in anterior epidural space posterior to L4-S1 space

Discussion

This case report highlights the need for further robust research to understand the risk of aesthetic surgeries on the abdominal wall on future pregnancies, maternal health and potential surgical difficulties during LSCS. It also highlights the anaesthetic dilemma regarding perioperative management including mode of anaesthesia, analgesia and its impact on mother and foetus.