It is often seen that patient complaints of chest pain, either in left side or in epigastrium, during cesarean section under spinal anesthesia. It specially seen during peritoneum stretching, uterus manipulation or rough handling of omentum etc. What is the probable cause and what should be the ideal prophylactic and therapeutic strategy?
The High Thoracic Block level is causing the discomfort of breath and dyspnea,
that may manifest as chest pain.Reassuring patients is effective in reducing discomfort and fear.
Peritoneal stretching cause referred pain in the chest as mention above.
Ischemia, oxyticin and not good enough block height are plausible causes
Though chest pain during cesarean section under spinal anesthesia is a common entity, the cause is still obscure and there are several hypothesis. Myocardial ischemia from oxytocin may cause chest pain but this is definitely not a common finding. High thoracic block and inadequate block height are not also the most common reason as there will be other obvious signs.
Hypotension may cause chest pain and it is common after abdominal delivery of the fetus due to hypovolemia, but the more obvious sign will be nausea and vomiting caused by decreased blood supply to chemoreceptor trigger zone (CTZ).
In my personal opinion, the most common cause of chest pain is probably due to peritoneum stretching leading to vagal stimulation. It is specially seen during peritoneal closure (some surgeons still do), uterus manipulation or rough handling of omentum etc. If unattended it can lead to bradycardia and even cardiac arrest. The most effective management is reassurance, sedation and atropine in vagolytic doses.
Again, chest pain under spinal anesthesia is not only unique to C-section, it is also seen during appendicectomy under spinal anesthesia, specially in male appendix probably due to anatomical variability. That is why GA is safer option during appendicectomy, at least theoretically.
Another explanation of chest pain is microembolism. When uterus is exteriorised and placed above abdomen, microembolism can occur due to concomitant hypotension (hypovolemia following abdominal delivery of fetus) and air entry into microvasculature. This microemboli can lodge in pulmonary circulation leading to chest pain. In support of this theory lies the fact that chest pain is seen in mainly those cases where uterus is exteriorised and placed above abdomen. If surgeons manipulate uterus within abdominal cavity, then the incidence of chest pain is very less. Some anesthesiologists like to administer prophylactic vasopressor beforehand to raise the BP and diminish the chance of microembolism and this technique do actually work!
It is fact that microembolism is definitely a cause for chest pain but this can not explain the occurrence of chest pain during appendicectomy under spinal anesthesia.
Causes of chest pain during c- section are multifactorial- in my opinion the most common cause seen in our set up is inadequate level of block.Usually a level of T 4 is recommended for safe delivery of baby, however in cases where this level is not achieved and surgeon tries delivery with external pressure on abdomen by assistants leads to chest pain.
Second cause in our set up being a high spinal block ,Level above T2 when patient do complain of difficulty breathing and chest pain.
Traction of peritoneal structures leading to chest pain denotes inadequate level of block while use of oxytocin may lead to the problem.
Incidence of electrocardiographic changes during cesarean delivery under regional anesthesia.
Palmer CM. Norris MC. Giudici MC. Leighton BL. DeSimone CA.
Anesthesia & Analgesia. 70(1):36-43, 1990 Jan.
What do electrocardiographic and echocardiographic changes during cesarean delivery mean?.
Palmer CM.
Anesthesia & Analgesia. 76(2):457, 1993 Feb.
Maternal electrocardiographic changes in the peripartum period.
Palmer CM.
International Journal of Obstetric Anesthesia. 3(2):63-6, 1994 Apr.
Postpartum hemorrhage is not the only setting for maternal myocardial ischemia.
Palmer CM.
Anesthesiology. 101(4):1036-7; author reply 1037-8, 2004 Oct.
AS you can see, this is not a recent topic. We hypothesized that chest pain during CS was due to myocardial ischemia over 20 years ago, but it was (and still is) difficult to prove or disprove definatively. I still believe it is a likely cause, and it is probably precipitated by the relative overdose of oxytocin we usually administer after delivery.
As per Dr. Anthea Hatfield, the author of "The Complete Recovery Room Book", air embolism is the most common cause of chest pain during cesarean section under regional blockade.
http://books.google.co.in/books?id=4dTQAgAAQBAJ&pg=PA191&lpg=PA191&dq=air+embolism+causing+chest+pain+in+cesarean+section+under+spinal&source=bl&ots=O1bmq1uRcn&sig=AmJmaRa2jh6pwl9uDoB83yh6qqU&hl=en&sa=X&ei=IC3bU835FLCX0QXym4GACg&ved=0CEkQ6AEwBg#v=onepage&q=air%20embolism%20causing%20chest%20pain%20in%20cesarean%20section%20under%20spinal&f=false
administration of oxytocin may be one of the causes as it causes substantial haemodynamic changes. Hypotension may be other cause.
We changed our policy from bolus injection oxytocine to infusion over time and this has reduced incidences of nausea hypotension and cardiac symptoms in my experience.
Publication see (not ours):Oxytocin administration during cesarean delivery: Randomized controlled trial to compare intravenous bolus with intravenous infusion regimen
Susmita Bhattacharya1, Sarmila Ghosh1, Debanjali Ray1, Suchismita Mallik1, Arpita Laha2
1 Department of Anaesthesiology, Burdwan Medical College, Kolkata, West Bengal, India
2 Department of Anaesthesiology, Calcutta Medical College, Kolkata, West Bengal, India
Date of Web Publication
10-Jan-2013
Background: Oxytocin is routinely administered during cesarean delivery for uterine contraction. Adverse effects are known to occur after intravenous oxytocin administration, notably tachycardia, hypotension, and electrokardiogram (EKG) changes, which can be deleterious in high-risk patients.
Conclusion: Bolus oxytocin (at a dose of 3 IU over 15 seconds) and infusion of oxytocin (at a dose of 3 IU over 5 minutes) have comparable uterotonic effect. However, the bolus regime shows significantly more adverse cardiovascular events.
I faced this problem frequently. if I found the patient was hemodynamically stable, only reassurance of the patient with subsequent more close observation was my response. I didn't find any abnormal sequelae ever.
One of my colleagues observed that it occurs only if the surgeon exteriorizes the uterus. This suggests that the chest pain may be due to venous gas embolism.
Most common causes are:1.Pitocin induce
2 .lnadequate level of spinal
3.Streching of peritoneum and traction due to inadequate level....
I mean due to pitocin induced tachycardia and I observed decreased symptoms by reducing the speed of pitocin(oxytocin)infusion.
Multifactorial ok.
Peritoneal stretch probably yes.
Inadequate spinal and chest pain??
My opinion: After spinal anesthesia, there is vasodilatation below the level of spinal anesthesia which causes compensatory vasoconstriction above spinal level. Blood loss during LSCS, placental removal, Pitocin drip cause further hypotension which again causes vasoconstriction above the level.
Vasoconstriction involves coronaries also which may cause transient angina-like symptoms due to decreased coronary perfusion (hypotension, tachycardia, vasoconstriction) increasing sudden oxygen demand.
I understand when there is an improper attention after the operation.