///2010 Abstract Details
2010 Abstract Details2018-05-01T17:52:49+00:00

Anesthetic management of a parturient with Transverse Myelitis

Abstract Number: 212
Abstract Type: Case Report/Case Series

Steve P Thomas MBChB FRCA1 ; Simon Massey MBChB FRCA MD2; Arry Kathirgamanathan MBChB FRCA3; Joanne Douglas MD FRCPC4

Anesthetic management of a parturient with Transverse Myelitis

Introduction

Transverse myelitis (TM) is a demyelinating disease of unclear etiology which may occur as a single episode or behave similarly to multiple sclerosis (MS) as a relapsing disease with variable recovery. As a rare condition, in a five year registry of high risk obstetric anesthetic patients with neurological disease, only a single case of TM was reported (1).

Case Report

A 27 year old parturient with TM presented to our Obstetric Anesthesia Clinic at 13 weeks gestation prior to an elective cerclage for cervical incompetence.

The parturients pregnancy had been uneventful and the consulting anesthesiologist recommended avoiding a neuraxial technique. Subsequently, the patient had a cervical cerclage under general anesthesia with endotracheal intubation. Succinylcholine was used uneventfully to provide muscle relaxation.

The cerclage was removed under epidural anesthesia using bupivacaine and the cervix immediately dilated to 4 cm. Labour was induced with oxytocin and patient controlled epidural analgesia was initiated. Later, the patient delivered a healthy baby.

Her postpartum period was complicated by underlying muscle weakness which gradually improved resulting in discharge six days postpartum.

Discussion

It is not known whether TM has relapses after pregnancy but there are several reported cases of TM following a neuraxial technique (2) and general anesthesia (3).

Use of neuraxial techniques in these patients remains controversial. Local anesthetic drugs are neurotoxic, lidocaine more than bupivacaine (4) and demyelinated fibers may be more susceptible to neurotoxicity. It has also been shown that spinal anesthesia has more potential for neurotoxicity than epidural anesthesia (5).

Using succinylcholine is also controversial in patients with evidence of denervated muscle due to increased expression of nicotinic neuromuscular acetylcholine receptors in skeletal muscle. This may lead to significant hyperkalaemia. The literature suggests it is wise not to use succinylcholine between 24 hours and 1-2 years after the insult (6).

References

(1). May AE et al. UK registry of high-risk obstetric anaesthesia: report on neurological disease. IJOA, 17 (2008) 31-36.

(2). Jha S et al. Transverse myelitis following spinal anesthesia. Neurology India, Dec, 2006: Vol.54, Issue 4, 425-427.

(3). Gutowski NJ. Transverse myelitis following general anaesthesia. Anaesthesia, 1993, Vol 48, pages 44-45.

(4). Johnson ME. Neurotoxicity of Lidocaine: Implications for Spinal Anesthesia and Neuroprotection. J Neurosurg Anesthesiol, Vol 16, Number1, Jan, 2004.

(5). Hebl JR et al. Neuraxial Anesthesia and Analgesia in Patients with Preexisting Central Nervous System Disorders. Regional Anesthesia. Vol.103, No.1, July, 2006.

(6). Naguib M et al. Advances in Neurobiology of the Neuromuscular Junction. Anesthesiology, Vol 96, No.1, Jan, 2002.

SOAP 2010