Spinal anesthesia for Cesarean delivery in a woman with neuromyelitis optica
Abstract Number: F-48
Abstract Type: Case Report/Case Series
An obese 22yo G1P0 with mixed ethnicity (Asian and African-American) diagnosed with neuromyelitis optica (NMO) in 2009 was found to be pregnant while on azathioprine. She was admitted for treatment of acute flares of NMO at 21, 24, 28 and 29 wks gestation. Symptoms included generalized body itching, excruciating allodynia and weakness preventing ambulation. MRI showed lesions in the cervical and thoracic spinal cord (Fig). Her first 3 flares were successfully treated with IV methylprednisolone and plasma exchanges. Symptoms continued to worsen during her 4th admission despite IV methylprednisolone, plasma exchanges, IVIG, and azathioprine. With no resolution of symptoms at 32 wks, a decision was made to undertake an elective Cesarean delivery. The neurology team thought that regional anesthesia (spinal or epidural) was not contra-indicated in this patient, despite her worsening sensory-motor deficits. A single shot spinal anesthetic was deemed preferable over a CSE, epidural or even continuous spinal (to avoid manipulation of the epidural/subarachnoid space with a 17G needle and epidural catheter), despite a BMI of 45. Two 18G IVs and an arterial line were placed. A spinal injection (HB bupivacaine 12mg, fentanyl 15mcg, morphine 200mcg) via a 25G Whitacre at presumed L4-L5 was uneventful. A phenylephrine infusion was started at 50mcg/min at the time of spinal dose. Despite a bilateral T4 level to pinprick, discomfort and intense allodynia only resolved with inhaled N20. The patient recovered entirely from the spinal anesthetic within 3-4h. A rituximab infusion was started 2 days later followed by a steroid taper. MRI 72h post-Cesarean showed lesions from C3-C5 and C7 (Fig). Symptoms rapidly improved and the patient was discharged for rehabilitation 10 days after delivery.
NMO, or Devic’s disease, is an idiopathic severe demyelinating disease of the CNS that preferentially affects the optic nerve and spinal cord. The NMO biomarker is an antibody to aquaporin-4 (AQP4), a water channel found on CNS astrocytes.(1) The safety of neuraxial anesthesia in MS has been established. Scarce reports of regional anesthesia in NMO are available and spinal anesthesia has even been associated with NMO (causality is however highly debated).(2-3) We report on the safe use of a single shot spinal in a woman with an acute flare of NMO likely caused by pregnancy.
1. PNAS 2012; 109:1001-2
2. Mult Scler 2003; 9:526-8
3. Eur J Anaesth 2010;27:578-80