Hongjun Duan

Mingzhang Zuo

Xiaoxi Li

BMC Anesthesiology

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Li et al. BMC Anesthesiology  (2015) 15:59 
DOI 10.1186/s12871-015-0048-2CASE REPORT Open AccessCase report: anesthesia management for
emergency cesarean section in a patient with
dwarfism
Xiaoxi Li1, Hongjun Duan2 and Mingzhang Zuo2*Abstract
Background: Dwarfism is characterized by short stature. Pregnancy in women with dwarfism is uncommon and
cesarean section is generally indicated for delivery. Patients with dwarfism are high-risk population for both general
and regional anesthesia, let alone in an emergency surgery.
Case presentation: In this case report we present a 27-year-old Chinese puerpera with dwarfism who underwent
emergency cesarean section under combined spinal and epidural anesthesia.
Conclusion: It is an original case report, which provides instructive significance for anesthesia management
especially combined spinal and epidural anesthesia in this rare condition. There was only one former article that
reported a puerpera who underwent combined spinal and epidural anesthesia for a selective cesarean section.
Keywords: Dwarfism, Cesarean section, AnesthesiaBackground
Dwarfism, defined as an adult height under 145 cm in
male or 135 cm in female, is a category of disorders with
extreme global growth failure [1]. Fertility rates for women
with dwarfism are generally low [2]. Puerperas with dwarf-
ism usually require delivery by cesarean section because of
contracted pelvis and cephalopelvic disproportion. How-
ever, anesthesia management in dwarfism is challenging,
for it is often complicated by conditions such as deformed
spine, limited neck mobility, and narrowed pharynx, lead-
ing to high-risk in both general anesthesia and regional
anesthesia. Here, we present you a successful case of the
anesthetic management in a puerpera with dwarfism
undergoing cesarean section.Case presentation
A 27-year-old primipara with dwarfism at 38 weeks gesta-
tion was presented to the OR for an emergency cesarean
section. She had typical features of disproportionate
dwarfism, with short limbs and lumber lordosis. She was
120 cm tall, largely made up of her head and body trunk,* Correspondence: zuomz@163.com
2Department of Anesthesiology, Beijing Hospital, Beijing 100730, China
Full list of author information is available at the end of the article
© 2015 Li et al.; licensee BioMed Central. This
Attribution License (http://creativecommons.o
reproduction in any medium, provided the or
Dedication waiver (http://creativecommons.or
unless otherwise stated.and weighed 63.5 kg. She had normal intelligence. Coex-
istent disorder in her mother suggests she may have a
positive family history. A magnetic resonance imaging
(MRI) scan of her spine taken before pregnancy showed a
spinal deformity (slight lumbar lordosis), but no cord
compressions. The level of termination of the spinal cord
was at the L1-2 interspace. No pre-existing cardiorespira-
tory dysfunction was found by pre-operational assessment.
Other laboratory results were normal. On spine examin-
ation, we found that her lumber intervertebral spaces were
palpable, but her thoracic intervertebral spaces were not.
Obstetrical ultrasound scan revealed that the fetus was
normally developed and in a transverse lie. After discus-
sion with the obstetrician and the patient, we planned to
administer combined spinal epidural anesthesia with a
backup plan of general anesthesia.
Routine non-invasive monitoring was established, in-
cluding non-invasive blood pressure (NBP), heart rate
(HR), pulse oximetry (SpO2), and electrocardiography
(ECG). Her baseline blood pressure (BP) and HR were
138/63 mmHg and 102/min, respectively. Her SpO2 was
99% while breathing room air and ECG results showed nor-
mal sinus rhythm. After intravenous access was obtained,
the patient was placed in the left lateral decubitus position.
3 ml of 1% lidocaine was used for local infiltrationis an Open Access article distributed under the terms of the Creative Commons
rg/licenses/by/4.0), which permits unrestricted use, distribution, and
iginal work is properly credited. The Creative Commons Public Domain
g/publicdomain/zero/1.0/) applies to the data made available in this article,
Li et al. BMC Anesthesiology  (2015) 15:59 Page 2 of 3anesthesia at L2-3 interspace. The epidural space was lo-
cated with a 17G Tuohy needle at the first attempt. Then a
25-gauge pencil-point spinal needle was inserted via the
Tuohy needle. After cerebrospinal fluid was detected,
1.4 ml 0.5% hypobaric bupivacaine was given into the sub-
arachnoid cavity, with the speed of 6 sec/ml. Finally, an epi-
dural catheter was placed into the epidural space. The
process was uneventful and patient restored her supine
position with the operating table slightly leaned to the left.
Almost instantly, the patient’s BP declined to 72/46 mmHg
and HR to 70/min. 10 mg Ephedrine was immediately ad-
ministered intravenously. At this stage, the block height
reached T4 bilaterally. After 0.2 mg Metaradrine was fur-
ther administered, her BP increased to 110/62 mmHg and
HR to 90/min. 5 minutes later, the block height remained
at T4 and surgery was started. With intermittent adminis-
tration of Ephedrine and Metaradrine, the patient’s BP was
remained between 90-100/55-62 mmHg. There were no
other complaints from the patient except for a slight feeling
of breathless, which was relieved after a male baby was de-
livered. Subsequently, the patient’s BP gradually increased
to 110-130/57-73 mmHg and remained stable during oper-
ation. The surgery lasted 30 minutes. The epidural catheter
was removed and the patient was transferred to the post-
operative anesthetic care unit for further observation. She
was sent back to the obstetric unit 1 hour later when the
block height declined to T6. The Apgar scores for the new-
born infant were 10 at 1 and 5 minutes respectively. No
peri-operative or anesthetic complications were observed.
The patient was discharged home three days later.
Discussion
People with dwarfism have generally been devided into
two categories: short-statured individuals with approxi-
mately normal anthropometric proportions and those
with disproportionate development, characterized by
short limbs or short trunks, which are deformed in many
cases. Among these, achondroplastic dwarfism is the
most common type of human dwarfism with a genetic
disorder of bone growth. It occurs in approximately 1 in
15,000 to 1 in 40,000 live births. Achondroplasia dwarf-
ism can be inherited in an autosomal dominant pattern.
However, 80% achondroplasia occurs with no family
history. The characteristic features of achondroplasia in-
clude typical facial features, disproportionate short stat-
ure, and an exaggerated lumbar lordosis. Severe spinal
deformity may also lead to cord compression. In our
case, according to her appearance, lack of dysgnosia, and
hereditary pattern, we consider the possibility that she
had achondroplasia, although the cause for her growth
deficiency is unknown.
The anesthetic management of the patient with dwarf-
ism for cesarean section presents significant challenge for
anesthesiologists, not only due to the pathophysiologicaldiversifications of various forms of dwarfism and relatively
rare pregnancy and labor in women with dwarfism, but
also due to poor bony landmarks, spinal deformity and no
standard guidelines for anesthetic management. The most
popular anesthetic management for cesarean section is
combined spinal epidural anesthesia. However, it may be
technically difficult to perform in the patients with signifi-
cant physical abnormalities, such as severe lumber lordo-
sis, spinal deformity, and potential cord compression. In
addition, the risk of intrathecal anesthesia for pregnant
patients with dwarfism is high due to a lack of X-ray
examination, which is not usually indicated for pregnant
patients. Therefore the severity of spinal deformity is often
difficult to be evaluated. In this case, the patient had
minor lumber lordosis, and she’s never had symptoms of
cord compression before. On examination, we were able
to palpate the intervertebral spaces in the patient’s lumbar
region. Therefore, we decided to administer combined
spinal epidural anesthesia. Noticeably, the patient has
small features but normal body trunk, and the volume of
subarachnoid and epidural spaces are uncertain. For pa-
tient like her, the most appropriate type and dose of local
anesthetics are unclear. Considering the length of her
body trunk is very close to that of normal adult, we specu-
lated that we should not calculate the dose of anesthetics
based only on her height. After careful consideration and
discussion, we decided to give her a relatively lower dose
(1.4 ml) of 0.5% hypobaric bupivacaine rather than routine
dose (1.8-1.9 ml) for spinal anesthesia. We also prepared
2% lidocaine for epidural anesthesia if needed. The patient
achieved a block height at T4 almost immediately after the
anesthesia procedure was accomplished and the surgery
was uneventful.
When we searched the literatures for the reference dos-
ages of anesthetics administered to the patients with dwarf-
isms afterwards, we noticed that the dosage we used was
consistent with that reported by Samra, who used the mini-
mum effective dose (providing effective spinal block in 95%
of the women undergoing cesarean section) of intrathecal
bupivacaine (0.06 mg/cm height) in a puerpera with achon-
droplasia, and achieved satisfying block height [3]. There-
fore, we recommend that the dosage of local anesthetics
used for spinal anesthesia in these patients should be no
more than 0.06 mg/cm height to avoid an exaggerated
block height leading to unstable hemodynamic. An epidural
catheter should always be placed whenever possible in case
of individual variation.
So far, the reports regarding regional anesthesia in pa-
tients with dwarfism undergoing cesarean section are
scarce. According to the previous reports including ours,
we believe local anesthesia is optional for cesarean
section [4-6]. Nevertheless, anesthesia poses a significant
risk to patients with dwarfism, which should be recog-
nized by all anesthesiologists. Preoperative assessments
Li et al. BMC Anesthesiology  (2015) 15:59 Page 3 of 3should be carefully made and the contraindications such
as severe spinal deformity or cord compression should be
ruled out. Patients’ X-rays, or MRI examination taken be-
fore pregnancy is helpful in preoperative evaluation. Local
anesthesia (spinal or epidural anesthesia) should be care-
fully planned. Close monitoring is important. Another op-
tion is to perform general anesthesia [2], in which case
difficult airway places great risk due to the conditions such
as big head and tongue, limited head extension, cervical
spine instability and relatively undeveloped pharynx.
Therefore, patients should be carefully evaluated to ex-
clude difficult airway using indicators such as Mallampati
classification, thyromental distance, sternomental distance.
Different techniques for management of difficult airway
should be prepared in advance. For patients with high risk
of difficult airway, awake intubation should be considered.
Postoperative recovery may be affected when impaired
cardiopulmonary function exists.
Conclusions
In our case report, we presented a successful anesthesia
management of a puerpera with dwarfism who underwent
emergency cesarean section. Patients with dwarfism are at
high-risk for both general and regional anesthesia, espe-
cially in emergency surgeries. However, with careful exam-
ination and evaluation, intraspinal anesthesia were
successfully planned and performed in our case. It pro-
vides instructive significance for anesthesia management
in this rare condition.
Consent
Written informed consent was obtained from the patient
for publication of this Case report. A copy of the written
consent is available for review by the Editor of this
journal.
Abbreviations
MRI: Magnetic resonance imaging; NBP: Non-invasive blood pressure;
HR: Heart rate; SpO2: Pulse oximetry; ECG: Electrocardiography; BP: Blood
pressure.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
XXL contributed to collection of data and writing the manuscript. HJD
contributed to performing of anesthesia. MZZ contributed to revising the
manuscript. All authors read and approved the final manuscript.
Acknowledgements
The authors would like to thank Yongsheng Miao from department of
anesthesiology of Beijing Hospital who assisted in the anesthesia
management of this case.
Author details
1Department of Anesthesiology, Beijing Cancer Hospital & Institute, Beijing
100142, China. 2Department of Anesthesiology, Beijing Hospital, Beijing
100730, China.Received: 16 November 2014 Accepted: 22 April 2015
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Case report: anesthesia management for emergency cesarean section in a patient with dwarfism

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Case report: anesthesia management for emergency cesarean section in a patient with dwarfism

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