Management of anesthesia during C-section of a multiple sclerosis pregnant woman: Case report and literature review

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It is of particular interest because of its diverse presentation, the difficulty for making a diagnosis, the concurrent factors leading to its development, and potential etiology.<a class="elsevierStyleCrossRefs" href="#bib0005">1–5</a> The prevalence of Multiple Sclerosis in Lima, Peru is of 7.69×100.000 inhabitants (95% confidence interval 7.09–8.30) which is an average prevalence for the area.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>There is agreement in Peru in saying that the Relapsing-Recurrent (RR) form is the most frequent form of MS, with a higher prevalence in females (2:1 ratio); the age of onset of the disease is in average 31.5 years of age and the delay in making the diagnosis is 3.8 years. The most frequent symptoms at the onset of the disease were optical neuritis (ON) (36%), motor symptoms (35%) and sensitive symptoms (33%). In the course of the disease other cerebellar (49%) and sensitive (47%) symptoms developed, in addition to sphincter involvement (42%).<a class="elsevierStyleCrossRef" href="#bib0035">7</a>The purpose of this paper was to present a clinical case regarding the management of anesthesia during a C-section in a pregnant woman with multiple sclerosis and to do a literature review.A comprehensive literature search was undertaken from 1985 to 2013, using Medline, Embase, Lilacs, Cochrane, Scielo (search criteria: cesarean section, anesthesia, and multiple sclerosis). Four clinical cases, a cohort trial and 3 reviews on the topic were identified (date of the search: October 18, 2013).Case reportA 26-year-old pregnant woman in her second pregnancy with 40 weeks in gestation was scheduled for emergency obstetric cesarean section at the Hospital Nacional Alberto Sabogal Sologuren, with diagnosis of fetal macrosomia, previous cesareada, prodromal labor.Medical history, diagnosis of intermittent relapsing multiple sclerosis with two years of evolution, with an onset of dysarthrya, hemiplegia and left facial paralysis. The last relapse was seven months ago and the patient received ambulatory treatment with 300mg oral gabapentin, and 100mg oral thiamine.The preoperative evaluation showed no associated conditions. The grandfather on the mother's side had a diagnosis of multiple sclerosis. The physical examination showed no evidence of motor deficit (the evaluation included paresis of the upper and lower limbs, in addition to cranial nerves) or sensory deficit (the patient was assessed using the pin-prick perception technique). The airway evaluation resulted in Mallampati II and the thyromental distance was >6cm. The blood tests revealed anemia and mild neutrophilia: there were no other laboratory findings. The surgical risk was level II and ASA II (inactive disease).Considering the standard C-section management and the absence of relevant contraindications, the decision was made to administer epidural anesthesia. The informed consent was obtained and the patient was informed about the possibility of a relapse of her disease after delivery (not only because of the regional anesthetic block).The heart rate, pulse oximetry, ECG, and blood pressure were all monitored at the OR. The patient was pre-hydrated with 500ml of 0.9% sodium chloride. The anesthesia was administered with the patient in a sitting position in the space between the third and the fourth lumbar vertebrae, using a 18-touhy needle for the administration of 2% lidocaine without epinephrine, for a total dose of 500mg.The evolution of the epidural anesthesia was evaluated with a sensitive block (based on pinch perception) of the dermatome T10 at 4min, peak sensitive block of the dermatome T5 at 25min; regression 2 dermatomes at 65min, regression to dermatome T10 at 130min.During the 60min of the surgical intervention, the patient did not experience any hypotension (lowering of the systolic blood pressure below 25% de la basal, systolic basal pressure 127mmHg and lowest recorded systolic pressure 115mmHg) or bradycardia (heart rate below 60), or any other complication derived from the anesthetic technique. The intraoperative analgesia was evaluated using the visual analog scale (0–10) with a score of 3 during the skin incision, the incision of the uterus, delivery and uterine exteriorization; 0 score during closure of the peritoneum and the skin. There was no need to administer any additional intraoperative analgesia. Metamizol 2g and dexamethasone 4mg were administered intravenously.The motor block was then assessed at the post-anesthesia care unit (PACU), with full recovery after 120min of the start of anesthesia. Postoperative pain was evaluated with VAS 3, 2h after the start of anesthesia, VAS 4 at 4h, 12h and 24h. There were no postoperative complications. A neurological evaluation was performed at 72h, 7 days and 30 days, showing no neurological complications or relapse of the disease (the motor deficit was evaluated in terms of paresis of the lower and upper limbs, in addition to the cranial nerves; the sensitive deficit was evaluated using the pin-prick perception technique).DiscussionMS is an acquired demyelinating neurological condition characterized by neurological remission of the symptoms, followed by neurological deficit and progressive disability as time passes.The medical research on the use of regional anesthesia in MS women are limited and in some cases the results are contradictory. Pre-existing neurological conditions are still a problem because of lawsuits and thus some anesthesiologists tend to prefer general anesthesia, as has been reported by Vercauteren and Heytens<a class="elsevierStyleCrossRef" href="#bib0040">8</a>, or in the retrospective trial by Drake et al.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> However, there is no strong proof about any serious consequences from regional anesthesia in these patients.Historically, the use of regional anesthesia techniques for this population of patients has been contraindicated for fear of further deteriorating the neurological evolution (patients with a history of neurological involvement may be more susceptible to injury when exposed to a secondary insult such as mechanical trauma, toxicity of the local anesthetic agent, neuronal ischemia).Some cases have been reported in the literature against regional anesthesia, such as Levesque et al.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>; nevertheless, some authors prefer using epidural anesthesia also in C-sections.<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a> However, following delivery other conditions may generate some confusion around the relapse of the disease: pregnancy, surgical stress, high temperature, breast feeding, and only at the end, anesthesia could be involved.During the last decade, many data suggest that loco-regional anesthesia is safe for these patients. Perlas and Chan<a class="elsevierStyleCrossRef" href="#bib0055">11</a> say that multiple sclerosis shall not be considered a contraindication for epidural anesthesia or for spinal anesthesia, and an in-depth discussion with the patient should take place emphasizing the available options.In a survey by Drake et al., obstetric anesthesia in the UK, the authors find divergent opinions; however, most would use a spinal block for C-section, although there are still some that would use epidural or general anesthesia, placing emphasis on the importance of completing the informed consent following a pre-anesthesia evaluation.Pasto et al<a class="elsevierStyleCrossRef" href="#bib0060">12</a> in his cohort trial on epidural anesthesia for C-section in MS patients showed that there is no correlation between epidural anesthesia and relapse or post-partum disability.The case herein discussed was a night emergency, so no prior neurological evaluation was available and the decision was made to administer epidural anesthesia (because of the advantage of being a slower onset block, with less hemodynamic changes because there is no direct contact between the local anesthetic agent and the bone marrow or the encephalon; besides, the patient is awake and able to see the baby). One of the main reasons for choosing this technique is the existence of a higher methodological quality trial showing the safety of epidural anesthesia; furthermore, by avoiding general anesthesia the manipulation of the airway – that in itself is considered a difficult airway – is also avoided. Our results were satisfactory in terms of the intraoperative anesthesia, while the length of the anesthesia is comparable to the healthy population treated in the same manner. No neurological deficits were identified during delivery or in the following 30 days.The decision must be based on a careful analysis of the risks and benefits for each individual patient, keeping in mind a comprehensive neurological evaluation and the patient's own preferences. In fact, many suggest that the patient should actively participate in the decision making process during the pre-anesthesia evaluation. A successful management could be possible with the cooperation of the anesthesiologist, the gynecologist, and the neurologist involved in the perinatal care of this high-risk group.Completing a detailed informed consent with the participation of the patient and the family is crucial to avoid medical-legal issues.According to the available studies, apparently the behavior of epidural anesthesia in MS pregnant women is similar to the behavior in pregnant women who do not have the disease.Based on the current information, it seems that postpartum women with multiple sclerosis have the same probability of relapse as any other MS patient.Conflicts of interestThe author has no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres412683" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec388409" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres412684" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec388408" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:2 [ "identificador" => "xack121982" "titulo" => "Acknowledgments" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-04-21" "fechaAceptado" => "2014-09-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec388409" "palabras" => array:5 [ 0 => "Multiple sclerosis" 1 => "Anesthesia" 2 => "Cesarean section" 3 => "Anesthesia epidural" 4 => "Pregnancy abdominal" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec388408" "palabras" => array:5 [ 0 => "Esclerosis Múltiple" 1 => "Anestesia" 2 => "Operacón Cesárea" 3 => "Anestesia Epidural" 4 => "Embarazo Abdominal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Case description of a pregnant woman at term with a history of Multiple Sclerosis, scheduled for C-section and with a diagnosis of fetal macrosomia; the patient had undergone a C-section in the past during pro-dromal labor. The physical examination showed no motor or sensory deficit. The CBC showed anemia and mild lymphocytosis. The patient underwent cesarean section under single-dose epidural anesthesia with no complications and favorable evolution. Multiple sclerosis is a rare neurological condition, even rarer in pregnant women undergoing C-section. So a literature search was undertaken aimed at improving the management of anesthesia in this group of patients." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Se describe el caso de una gestante a término de 26 años con antecedente de Esclerosis Múltiple programada a cesárea con diagnóstico de macrosomía fetal y cesareada anterior una vez, en pródromos de trabajo de parto. Al examen físico no déficit motor ni sensitivo. Hemograma anemia y linfocitosis leve. La paciente fue sometida a cesárea con anestesia epidural dosis única sin complicaciones y con evolución favorable. La esclerosis múltiple es una enfermedad neurológica poco frecuente y aún menos frecuente en gestantes con esclerosis múltiple sometida a cesárea por lo que se realizó una búsqueda de la literatura para un mejor manejo anestésico de este grupo de pacientes." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Christopher QRA. Manejo anestésico en cesárea de una gestante con esclerosis múltiple: Reporte de un caso y revisión de la literatura. Rev Colomb Anestesiol. 2015;43:104–106." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Valoración preoperatoria de los pacientes con enfermedades neurológicas y neuromusculares" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "X. Santiveri Papiol" 1 => "J. 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Case report

Manejo anestésico en cesárea de una gestante con esclerosis múltiple: Reporte de un caso y revisión de la literatura

Angel Christopher Quispe Ricci

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angelchristopherqr@yahoo.es

Corresponding author at: Hospital Nacional Alberto Sabogal Sologuren, Jr Colina 1081 Bellavista callao, Perú.

Departamento Anestesiología del Hospital Nacional Alberto Sabogal Sologuren, Lima, Perú

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It is of particular interest because of its diverse presentation, the difficulty for making a diagnosis, the concurrent factors leading to its development, and potential etiology.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;5</span></a> The prevalence of Multiple Sclerosis in Lima, Peru is of 7.69<span class="elsevierStyleHsp" style=""></span>&times;<span class="elsevierStyleHsp" style=""></span>100.000 inhabitants (95% confidence interval 7.09&#8211;8.30) which is an average prevalence for the area.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There is agreement in Peru in saying that the Relapsing-Recurrent (RR) form is the most frequent form of MS, with a higher prevalence in females (2:1 ratio); the age of onset of the disease is in average 31.5 years of age and the delay in making the diagnosis is 3.8 years. The most frequent symptoms at the onset of the disease were optical neuritis (ON) (36%), motor symptoms (35%) and sensitive symptoms (33%). In the course of the disease other cerebellar (49%) and sensitive (47%) symptoms developed, in addition to sphincter involvement (42%).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The purpose of this paper was to present a clinical case regarding the management of anesthesia during a C-section in a pregnant woman with multiple sclerosis and to do a literature review.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A comprehensive literature search was undertaken from 1985 to 2013, using Medline, Embase, Lilacs, Cochrane, Scielo (search criteria: cesarean section, anesthesia, and multiple sclerosis). Four clinical cases, a cohort trial and 3 reviews on the topic were identified (date of the search: October 18, 2013).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 26-year-old pregnant woman in her second pregnancy with 40 weeks in gestation was scheduled for emergency obstetric cesarean section at the Hospital Nacional Alberto Sabogal Sologuren, with diagnosis of fetal macrosomia, previous cesareada, prodromal labor.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Medical history, diagnosis of intermittent relapsing multiple sclerosis with two years of evolution, with an onset of dysarthrya, hemiplegia and left facial paralysis. The last relapse was seven months ago and the patient received ambulatory treatment with 300<span class="elsevierStyleHsp" style=""></span>mg oral gabapentin, and 100<span class="elsevierStyleHsp" style=""></span>mg oral thiamine.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The preoperative evaluation showed no associated conditions. The grandfather on the mother&#39;s side had a diagnosis of multiple sclerosis. The physical examination showed no evidence of motor deficit (the evaluation included paresis of the upper and lower limbs, in addition to cranial nerves) or sensory deficit (the patient was assessed using the pin-prick perception technique). The airway evaluation resulted in Mallampati II and the thyromental distance was &#62;6<span class="elsevierStyleHsp" style=""></span>cm. The blood tests revealed anemia and mild neutrophilia: there were no other laboratory findings. The surgical risk was level II and ASA II (inactive disease).</p><p id="par0035" class="elsevierStylePara elsevierViewall">Considering the standard C-section management and the absence of relevant contraindications, the decision was made to administer epidural anesthesia. The informed consent was obtained and the patient was informed about the possibility of a relapse of her disease after delivery (not only because of the regional anesthetic block).</p><p id="par0040" class="elsevierStylePara elsevierViewall">The heart rate, pulse oximetry, ECG, and blood pressure were all monitored at the OR. The patient was pre-hydrated with 500<span class="elsevierStyleHsp" style=""></span>ml of 0.9% sodium chloride. The anesthesia was administered with the patient in a sitting position in the space between the third and the fourth lumbar vertebrae, using a 18-touhy needle for the administration of 2% lidocaine without epinephrine, for a total dose of 500<span class="elsevierStyleHsp" style=""></span>mg.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The evolution of the epidural anesthesia was evaluated with a sensitive block (based on pinch perception) of the dermatome T10 at 4<span class="elsevierStyleHsp" style=""></span>min, peak sensitive block of the dermatome T5 at 25<span class="elsevierStyleHsp" style=""></span>min; regression 2 dermatomes at 65<span class="elsevierStyleHsp" style=""></span>min, regression to dermatome T10 at 130<span class="elsevierStyleHsp" style=""></span>min.</p><p id="par0050" class="elsevierStylePara elsevierViewall">During the 60<span class="elsevierStyleHsp" style=""></span>min of the surgical intervention, the patient did not experience any hypotension (lowering of the systolic blood pressure below 25% de la basal, systolic basal pressure 127<span class="elsevierStyleHsp" style=""></span>mmHg and lowest recorded systolic pressure 115<span class="elsevierStyleHsp" style=""></span>mmHg) or bradycardia (heart rate below 60), or any other complication derived from the anesthetic technique. The intraoperative analgesia was evaluated using the visual analog scale (0&#8211;10) with a score of 3 during the skin incision, the incision of the uterus, delivery and uterine exteriorization; 0 score during closure of the peritoneum and the skin. There was no need to administer any additional intraoperative analgesia. Metamizol 2<span class="elsevierStyleHsp" style=""></span>g and dexamethasone 4<span class="elsevierStyleHsp" style=""></span>mg were administered intravenously.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The motor block was then assessed at the post-anesthesia care unit (PACU), with full recovery after 120<span class="elsevierStyleHsp" style=""></span>min of the start of anesthesia. Postoperative pain was evaluated with VAS 3, 2<span class="elsevierStyleHsp" style=""></span>h after the start of anesthesia, VAS 4 at 4<span class="elsevierStyleHsp" style=""></span>h, 12<span class="elsevierStyleHsp" style=""></span>h and 24<span class="elsevierStyleHsp" style=""></span>h. There were no postoperative complications. A neurological evaluation was performed at 72<span class="elsevierStyleHsp" style=""></span>h, 7 days and 30 days, showing no neurological complications or relapse of the disease (the motor deficit was evaluated in terms of paresis of the lower and upper limbs, in addition to the cranial nerves; the sensitive deficit was evaluated using the pin-prick perception technique).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">MS is an acquired demyelinating neurological condition characterized by neurological remission of the symptoms, followed by neurological deficit and progressive disability as time passes.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The medical research on the use of regional anesthesia in MS women are limited and in some cases the results are contradictory. Pre-existing neurological conditions are still a problem because of lawsuits and thus some anesthesiologists tend to prefer general anesthesia, as has been reported by Vercauteren and Heytens<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>, or in the retrospective trial by Drake et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However, there is no strong proof about any serious consequences from regional anesthesia in these patients.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Historically, the use of regional anesthesia techniques for this population of patients has been contraindicated for fear of further deteriorating the neurological evolution (patients with a history of neurological involvement may be more susceptible to injury when exposed to a secondary insult such as mechanical trauma, toxicity of the local anesthetic agent, neuronal ischemia).</p><p id="par0075" class="elsevierStylePara elsevierViewall">Some cases have been reported in the literature against regional anesthesia, such as Levesque et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>; nevertheless, some authors prefer using epidural anesthesia also in C-sections.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> However, following delivery other conditions may generate some confusion around the relapse of the disease: pregnancy, surgical stress, high temperature, breast feeding, and only at the end, anesthesia could be involved.</p><p id="par0080" class="elsevierStylePara elsevierViewall">During the last decade, many data suggest that loco-regional anesthesia is safe for these patients. Perlas and Chan<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> say that multiple sclerosis shall not be considered a contraindication for epidural anesthesia or for spinal anesthesia, and an in-depth discussion with the patient should take place emphasizing the available options.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In a survey by Drake et al., obstetric anesthesia in the UK, the authors find divergent opinions; however, most would use a spinal block for C-section, although there are still some that would use epidural or general anesthesia, placing emphasis on the importance of completing the informed consent following a pre-anesthesia evaluation.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Pasto et al<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> in his cohort trial on epidural anesthesia for C-section in MS patients showed that there is no correlation between epidural anesthesia and relapse or post-partum disability.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The case herein discussed was a night emergency, so no prior neurological evaluation was available and the decision was made to administer epidural anesthesia (because of the advantage of being a slower onset block, with less hemodynamic changes because there is no direct contact between the local anesthetic agent and the bone marrow or the encephalon; besides, the patient is awake and able to see the baby). One of the main reasons for choosing this technique is the existence of a higher methodological quality trial showing the safety of epidural anesthesia; furthermore, by avoiding general anesthesia the manipulation of the airway &#8211; that in itself is considered a difficult airway &#8211; is also avoided. Our results were satisfactory in terms of the intraoperative anesthesia, while the length of the anesthesia is comparable to the healthy population treated in the same manner. No neurological deficits were identified during delivery or in the following 30 days.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The decision must be based on a careful analysis of the risks and benefits for each individual patient, keeping in mind a comprehensive neurological evaluation and the patient&#39;s own preferences. In fact, many suggest that the patient should actively participate in the decision making process during the pre-anesthesia evaluation. A successful management could be possible with the cooperation of the anesthesiologist, the gynecologist, and the neurologist involved in the perinatal care of this high-risk group.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Completing a detailed informed consent with the participation of the patient and the family is crucial to avoid medical-legal issues.</p><p id="par0110" class="elsevierStylePara elsevierViewall">According to the available studies, apparently the behavior of epidural anesthesia in MS pregnant women is similar to the behavior in pregnant women who do not have the disease.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Based on the current information, it seems that postpartum women with multiple sclerosis have the same probability of relapse as any other MS patient.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>"
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            0 => "Esclerosis Múltiple"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case description of a pregnant woman at term with a history of Multiple Sclerosis, scheduled for C-section and with a diagnosis of fetal macrosomia; the patient had undergone a C-section in the past during pro-dromal labor. The physical examination showed no motor or sensory deficit. The CBC showed anemia and mild lymphocytosis. The patient underwent cesarean section under single-dose epidural anesthesia with no complications and favorable evolution. Multiple sclerosis is a rare neurological condition, even rarer in pregnant women undergoing C-section. So a literature search was undertaken aimed at improving the management of anesthesia in this group of patients.</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se describe el caso de una gestante a t&eacute;rmino de 26 a&ntilde;os con antecedente de Esclerosis M&uacute;ltiple programada a ces&aacute;rea con diagn&oacute;stico de macrosom&iacute;a fetal y cesareada anterior una vez, en pr&oacute;dromos de trabajo de parto. Al examen f&iacute;sico no d&eacute;ficit motor ni sensitivo. Hemograma anemia y linfocitosis leve. La paciente fue sometida a ces&aacute;rea con anestesia epidural dosis &uacute;nica sin complicaciones y con evoluci&oacute;n favorable. La esclerosis m&uacute;ltiple es una enfermedad neurol&oacute;gica poco frecuente y a&uacute;n menos frecuente en gestantes con esclerosis m&uacute;ltiple sometida a ces&aacute;rea por lo que se realiz&oacute; una b&uacute;squeda de la literatura para un mejor manejo anest&eacute;sico de este grupo de pacientes.</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Christopher QRA. Manejo anest&eacute;sico en ces&aacute;rea de una gestante con esclerosis m&uacute;ltiple: Reporte de un caso y revisi&oacute;n de la literatura. Rev Colomb Anestesiol. 2015;43:104&#8211;106.</p>"
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                      "titulo" => "Multiple sclerosis revealed by spinal anesthesia"
                      "autores" => array:1 [
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                          "etal" => false
                          "autores" => array:5 [
                            0 => "P. Levesque"
                            1 => "T. Marsepoilt"
                            2 => "P. Ho"
                            3 => "P.H. Venutolo"
                            4 => "J.M. Lesouefjm"
                          ]
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                        "fecha" => "1988"
                        "volumen" => "7"
                        "paginaInicial" => "68"
                        "paginaFinal" => "70"
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                          "autores" => array:2 [
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                      "doi" => "10.1007/BF03016521"
                      "Revista" => array:6 [
                        "tituloSerie" => "Can J Anaesth"
                        "fecha" => "2005"
                        "volumen" => "52"
                        "paginaInicial" => "454"
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                        "link" => array:1 [
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Article information

ISSN: 22562087
Original language: English

DOI:10.1016/j.rcae.2014.09.002

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	3	0	3
2024 October	61	7	68
2024 September	76	2	78
2024 August	58	1	59
2024 July	74	12	86
2024 June	64	2	66
2024 May	49	5	54
2024 April	44	2	46
2024 March	59	3	62
2024 February	55	7	62
2024 January	96	7	103
2023 December	55	14	69
2023 November	66	12	78
2023 October	87	11	98
2023 September	60	3	63
2023 August	45	3	48
2023 July	42	6	48
2023 June	48	1	49
2023 May	53	4	57
2023 April	28	2	30
2023 March	33	8	41
2023 February	19	1	20
2023 January	21	2	23
2022 December	11	5	16
2022 November	23	4	27
2022 October	15	7	22
2022 September	16	10	26
2022 August	12	12	24
2022 July	14	5	19
2022 June	22	6	28
2022 May	33	7	40
2022 April	23	7	30
2022 March	29	8	37
2022 February	25	6	31
2022 January	21	7	28
2021 December	13	13	26
2021 November	8	5	13
2021 October	14	8	22
2021 September	6	8	14
2021 August	6	7	13
2021 July	7	10	17
2021 June	7	5	12
2021 May	4	6	10
2021 April	10	24	34
2021 March	4	4	8
2021 February	3	7	10
2021 January	5	7	12
2020 December	3	3	6
2020 November	5	4	9
2020 October	2	5	7
2020 September	5	6	11
2020 August	4	11	15
2020 July	6	7	13
2020 June	10	3	13
2020 May	7	2	9
2020 April	3	1	4
2020 March	4	4	8
2020 February	6	3	9
2020 January	5	2	7
2019 December	10	9	19
2019 November	2	2	4
2019 October	10	0	10
2019 September	1	2	3
2019 July	0	5	5
2019 June	4	1	5
2019 May	1	8	9
2019 February	0	1	1
2018 December	0	1	1
2018 September	1	2	3
2018 August	0	2	2
2018 June	10	1	11
2018 May	55	6	61
2018 April	76	10	86
2018 March	73	9	82
2018 February	50	9	59
2018 January	87	9	96
2017 December	59	8	67
2017 November	94	5	99
2017 October	85	13	98
2017 September	92	8	100
2017 August	93	10	103
2017 July	84	4	88
2017 June	91	19	110
2017 May	96	9	105
2017 April	91	14	105
2017 March	85	35	120
2017 February	132	12	144
2017 January	93	12	105
2016 December	118	20	138
2016 November	147	11	158
2016 October	163	13	176
2016 September	262	14	276
2016 August	185	15	200
2016 July	88	10	98
2016 June	0	22	22
2016 May	2	31	33
2016 March	2	21	23
2016 February	5	26	31
2016 January	0	16	16
2015 December	46	16	62
2015 November	118	22	140
2015 October	162	15	177
2015 September	151	12	163
2015 August	140	15	155
2015 July	150	19	169
2015 June	89	14	103
2015 May	125	17	142
2015 April	96	15	111
2015 March	83	10	93
2015 February	78	14	92
2015 January	33	9	42

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