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

Thoracic epidural anesthesia for cesarean section in a parturient with mid-thoracic level paraplegia and preterm twin gestation

Abstract Number: 45
Abstract Type: Case Report/Case Series

Nicholas P McKernan MD1 ; Lisa M Councilman MD2; Jolene D Bean-Lijewski MD3

Introduction: Each year spinal cord injuries (SCI) affect 40/1,000,000 people in the US, many of child-bearing age. Life expectancy one year after SCI is 90% of normal, and many women, up to 14%, become pregnant after such an injury.2 Autonomic hyperreflexia (AHR) is a life-threatening complication in patients with SCI at or above T6 and is of particular concern in pregnancy, as the stress of uterine contractions during labor or surgical stimulation during cesarean section (C/S) may trigger life-threatening hypertension. We present a case in which a thoracic epidural was successfully used to prevent AHR during C/S of twins in a parturient with a history of SCI.

Case: A 37-year-old G2P0101 with a 32-week gestation twin pregnancy presented for a repeat C/S. Her medical history was significant for a motor vehicle accident at age 17 causing T4 SCI with resulting sensory deficits and paraplegia. Her injuries required multiple back surgeries from T6-L5, the most recent performed two years prior to this pregnancy. During labor with her first child, the patient had an epidural placed at L4-5 which was also used successfully for AHR prevention during the subsequent C/S. For the current repeat C/S, attempts at placement of an epidural and subarachnoid blocks in the lumbar region were unsuccessful utilizing both midline and paramedian approaches. This difficulty was attributed to scarring secondary to previous surgeries. Insertion of an epidural catheter was successful at the T6-7 interspace using the paramedian approach. A 17 gauge catheter was inserted and a test dose of 3mL of 1.5% lidocaine with 15mcg of epinephrine was administered. After the negative test dose, 6mL of 2% lidocaine in divided doses was administered via the epidural catheter. The patients baseline sensory deficit began at T4. A sensory level was achieved at the C7-T1 level while sensation at C5-6 remained intact. The C/S proceeded uneventfully without any signs of autonomic instability.

Discussion: In pregnant patients with SCI, regional anesthesia for prevention of AHR is critical for good maternal and fetal outcomes. This proved challenging in our patient due to surgical scarring. The thoracic epidural permitted gradual administration of local anesthetic so that loss of diaphragmatic function due to excessively high block could be avoided. It also provided sufficient blockade to prevent AHR. Although we were prepared to induce general anesthesia (GA) in the event of respiratory insufficiency, we hoped to avoid additional risks inherent to GA for this patient. Prevention of AHR without regional anesthesia may require potent vasodilator therapy and invasive intra-arterial blood pressure monitoring.

References:

1) National Spinal Cord Injury Statistical Center, Birmingham, AL. Annual Report for the Model Spinal Care systems 2005.

2) Jackson AB, Wadley V.A multicenter study of women's self-reported reproductive health after SCI. Arch Phys Med Rehab 1999 Nov;80(11):1420-8.

SOAP 2009