three. A detailed analysis report of the sample
revealed the composition of fluid as “interstitial”
consistent with edema fluid. Results were shared
with the patient. She was counseled and was
reassured accordingly. Patient was discharged
home on post-operative day four.
Discussion
Pregnancy affects almost every organ system.
These changes can be attributed to the
wide-spread physiological and anatomical adaptations
associated with normal pregnancy.
These are mainly cardiovascular, metabolic, and
endocrinological in nature. Clinical symptoms
like nausea, fatigue, constipation, weight gain,
mood changes, gastroesophageal reflux, and
peripheral edema are common. 1 As gestation
advances, these changes can become more significant
and may lead to several complications.
In the state of normal physiology, capillary hydraulic
pressure and intravascular protein are
the main factors determining the volume of
intra and extravascular compartments. During
pregnancy due to an increase in cardiac output,
reduction in systemic vascular resistance,
increase in blood volume, and variability in protein
production, peripheral edema develops in
dependent areas of the body. 1 Parturient with
twin gestations undergo remarkable pregnancy
changes compared to singleton counterparts.
Therefore, they are at increased risk of developing
severe peripheral edema as well as other
complications. 2 Our patient had twin gestation
and developed significant edema over the
course of the entire pregnancy. She remained
otherwise healthy and did not develop any other
major issues.
Neuraxial anesthetic techniques have made
a remarkable difference in recent years, making
labor a “non-laborious” event. Occasionally,
however, it can also lead to a diagnostic dilemma
like in our case. Leakage of fluid from neuraxial
block site has been reported very infrequently
in the literature. 3,4,5,6,7,8 Of note, the majority
of reports mainly describe the composition of
fluid as cerebrospinal fluid (CSF) secondary to
a CSF-cutaneous fistula. 3,4,5,6 Although other
causes like trauma, surgery, lumbar drains, infection,
and tumors can result in the formation
of CSF-cutaneous fistula, in anesthesia practice,
a dural puncture during placement of neuraxial
anesthetic blocks is the most likely cause. 3,4 Considering
the recent history of epidural catheter
placement, removal, and temporal relationship
to the symptoms, similar concerns were raised
by the primary team in our case as well. Even
though there was a possibility of an epidural
catheter puncturing the subarachnoid space
resulting in CSF-cutaneous fistula in our patient,
the incidence is still rare. On the other hand,
combined spinal-epidural anesthesia is associated
more commonly with CSF-cutaneous fistula,
which our patient did not receive. Only two
case reports are published to date discussing
the leakage of interstitial fluid through epidural
puncture site in, and only one of them was in an
obstetric patient similar to our case. 7-8 It is postulated
that a fistulous tract is created by epidural
catheter, providing the path of least resistance
for edema fluid to leak out from an area of
high pressure (dependent edema) to the area of
low pressure (surface of the skin). 7,8 In previously
reported cases, patients had preeclampsia. This
was absent in our patient. All cases resolved
spontaneously over a few days without requiring
skin closure or blood patch. Symptoms were
completely resolved in our patient on post-operative
day three. It can be difficult to differentiate
CSF and interstitial fluid clinically; therefore,
biochemical analysis is warranted. It was the
most common test performed to assess composition
of leaking fluid in all case reports. Testing
for the presence of CSF-specific acetyl cholinesterase
using protein electrophoresis can also be
used to differentiate CSF from interstitial fluid.
In the case of insufficient fluid collection for testing,
myelography using radioisotope can also
lead to the diagnosis of CSF leak.
Expecting the unexpected is not common.
Frequent causes always top the list for differential
diagnosis. It is not until one faces a rare clinical
scenario that things start to change. Patients
are in their most vulnerable state when presenting
for medical and/or surgical treatments.
Anything other than the norm will terrify them
and may change their perception for future interactions.
Our patient was surprised as well
as scared with her clinical course. Prompt diagnosis
and management helped us maintain
her confidence in her care team and medical
system as a whole. It is the responsibility of
a physician to address concerns and counsel
patients and their families in case of unusual
clinical outcome.
Understanding the significance of timely diagnosis
and management is essential, especially
when unusual clinical experience can change
one’s view point on medical and/or surgical
options. This case in particular provides insight
into the physician’s responsibility regarding
patient counseling, education, and preventing
misconceptions.
References
1. Chestnut DH. Physiologic Changes of Pregnancy.
Chestnut’s Obstetrics Anesthesia:
Principles and Practices. 5 th ed. Philadelphia,
PA: Elsevier; 2014
2. Kametas NA, McAuliffe F, Krampl E, et al. Maternal
cardiac function in twin pregnancy.
Obstet Gynecol. 2003 (Oct); 102:806-15.
3. Chan BO, Paech MJ. Persistent cerebrospinal
fluid leak: A complication of the combined
spinal-epidural technique. Anesth Analg.
2004 (Mar); 98(3): 828–30.
4. Hullander M, Leivers D. Spinal cutaneous fistula
following continuous spinal anesthesia.
Anesthesiology. 1992 (Jan); 76(1):139-40.
5. Joseph D, Anwari JS. Cerebrospinal fluid
cutaneous fistula after labour epidural analgesia.
Middle East J. Anesthesiol. 2001 (Jun);
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6. Howes J, Lenz R. Cerebrospinal fluid cutaneous
fistula: An unusual complication of
epidural anesthesia.Anaesthesia 1994 (Mar);
49(3):221–2.
7. Ennis M, Brock-Utne JG. Delayed cutaneous
fluid leak from the puncture hole after removal
of an epidural catheter. Anaesthesia,
1993 (Apr); 48(4):317-8.
8. Dalal KS, Shrividya C. Cutaneous fluid leakage
after epidural catheter removal. J of Anaesthesiol.
Clin Pharmacol. 2015 (Jan-Mar);
31(1):133-4.
Volume 117 • Number 3 SEPTEMBER 2020 • 59