///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Neuraxial Anesthesia in a Gravid Patient with Venous Sinus Thrombosis In Setting of Fetal Umbilical Vein Varix

Abstract Number: 227
Abstract Type: Case Report/Case Series

Shafonya m Turner B.S., M.D.1 ; Smith Kathleen B.S., M.D.2; Arnette Rhonda B.S., M.D.3

A 36 year old gravida 3, para 2-0-0-2 patient presented at 31 weeks and 3 days for a follow up ultrasound study of a previously identified fetal anomaly, mild left ventriculomegaly. The study showed resolution of the intracranial findings but identified a new fetal umbilical vein varix. Previous pregnancies resulted in normal infants. Secondary to the potentially fatal condition of the fetus, the patient was admitted for fetal surveillance and amniocentesis.

On the second day of admission the patient developed a severe headache. The patient had a long history of sinus headache, as well as rare migraines. After an extensive history and physical examination, conservative therapy did not improve her symptoms. Magnetic resonance imaging confirmed the diagnosis of venous sinus thrombosis. Anticoagulation therapy was initiated with heparin infusion desiring a goal prothrombin time (aPTT) of 44-75 seconds. Upon delivery of the fetus, warfarin therapy would be initiated.

At the preference of the patient, protamine reversal was to be avoided, therefore scheduled preterm delivery was planned. On the day of surgery, the patients heparin was held. Measured aPTT was 33.5 seconds 4 hours after its discontinuation. An atraumatic subarachnoid block was placed in the upright position. Surgical anesthesia was achieved to the T4 dermatome bilaterally. The patient tolerated the procedure well, and the infant was born with APGARs of 8 and 9 at 1 and 5 minutes, respectively.

Post-operatively, the patient recovered strength and sensation in the affected dermatomes. The patient was started on oral coumadin with a therapeutic goal INR of 2-3. She was seen several times for continued headache over several weeks post delivery. Three weeks after delivery, repeat MRI showed improvement of her thrombosis despite sub-therapeutic INR values. The final diagnosis of her continued headaches was sinusitis. The patients anticoagulation therapy has since been discontinued and she is asymptomatic.

In the setting of increased risk of thrombotic events during pregnancy, care must be taken to keep in mind the effect these events may have on the developing fetus. This case illustrates a well executed example of the interdisciplinary approach to caring for a patient and how clear communication and patient understanding often leads to positive results. The risks and benefits of a chosen care plan are always weighed; however the wishes of the patient and/or family are of grea



SOAP 2009