Combined spinal-epidural anesthesia for term Caesarean delivery following complete T4 spinal cord transection at 15 weeks gestation
Abstract Number: 129
Abstract Type: Case Report/Case Series
Fetal survival following maternal spinal cord injury during pregnancy is rare(1). Our patient sustained complete spinal cord transection at T4 and fractures of her clavicle, ribs, sternum and occipital condyle at 15 weeks gestation. She underwent a T2-T7 posterior spinal fusion and inferior vena cava filter placement. At discharge, she was insensate below the level of her injury, had neurogenic bowel and bladder, and orthostatic hypotension that was treated with oral midodrine. She was readmitted for urosepsis at 20 weeks gestation and developed signs of autonomic hyperreflexia during that admission. Since both the patient and her obstetricians desired a Caesarean delivery, our challenge was to provide an anesthetic that would prevent perioperative autonomic hyperreflexia, avoid high neuraxial block resulting in respiratory compromise or failure, and satisfy the patient's request to remain awake for delivery. We directly monitored blood pressure via an arterial catheter. We performed a combined spinal-epidural anesthetic with 7.5 mg hyperbaric spinal bupivicaine to provide adequate sacral anesthesia. After a negative test dose with lidocaine 1.5% with epinephrine, the catheter was dosed with a 5ml mixture of equal volumes of bupivicaine 0.5% and lidocaine 2%. We confirmed a T3-T4 sensory level when she detected tingling in her fingers. She did not complain of shortness of breath. An epidural infusion of bupivicaine 0.1% with fentanyl 2 ug/ml was continued 48 hours postoperatively to prevent autonomic hyperreflexia from fundal massage manuevers, incisional pain, and bladder catheterization.
Results: Our patient did not develop perioperative autonomic hyperreflexia. Incremental epidural catheter dosing avoided respiratory compromise which could have occurred if a single injection spinal anesthetic had been used. She remained hemodynamically stable until both she and her baby were discharged on postoperative day four.
Reference: 1.Slowronski E,Harman K. Obstetrice management following traumatic tetraplegia:case series and literature review Aust NZ J Obstet Gynaecol 2008;48:485-91