Anesthesia for urgent sequential ventriculoperitoneal shunt revision and cesarean delivery

Many women with cerebrospinal shunts are now reaching the childbearing age and may face risks from shunt malfunction during pregnancy. We report on a case of a 35-year-old primigravida at 36 weeks of gestation who was admitted to our hospital because of headache and cognitive and visual disturbances. At 13 years of age the patient had had a ventriculoperitoneal shunt for hydrocephalus related to an aqueduct stenosis. A computerized tomography scan of the brain showed moderate ventricular dilatation likely resulting from a malfunctioning shunt. On the second day after admission her level of consciousness and neurologic condition suddenly worsened and a second brain scan showed further enlargement of the ventricular system. After multidisciplinary consultation, it was decided to proceed with urgent sequential shunt revision and cesarean delivery. Anesthetic considerations included the risk of difficult airway, rising intracranial pressure and conflicting demands between neurological and obstetrical procedures (such as deep versus low-dose anesthesia). General anesthesia was provided with an oxygen/air mixture (50/50%), i.v. fentanyl (5 microg/kg total dose) and i.v. propofol infusion (4-6 mg kg(-1) h(-1)). Surgical procedures were carried out without complications and both mother and infant were doing well at a 6-month follow-up. An interdisciplinary approach allowed two urgent sequential operations to be performed with a unique anesthetic regimen and excellent maternal and fetal outcome.