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Cesarean Delivery of Patient with a Vagal Nerve Stimulator (VNS)
Abstract Number: F-53
Abstract Type: Case Report/Case Series
A 36-year-old G1P0 with a history of VNS placement for a refractory seizure disorder presented at 39 weeks gestation for cesarean delivery. She had experienced complex partial seizures since age 13, presumably arising from a frontoparietal arteriovenous malformation (AVM). Multiple radiosurgeries and embolizations had been performed but did not decrease seizure frequency. Following these surgeries, the patient’s seizures began to generalize. For seizure control during her pregnancy, the patient took oxcarbazepine, lamotrigine, and levitiracetam, all of which were at therapeutic levels. However, like one third of seizure patients, this patient’s seizures were not well controlled on oral medications. A VNS was placed prior to pregnancy, which could prevent her partial seizures from generalizing, an event often preceded by a sensory aura in the left hip. VNS have proved helpful in refractory seizure disorders[1,2] and in pregnant women there is no evidence of teratogenicity or other harm to the fetus. On the other hand, polytherapy with antiepileptics is thought to contribute to reduced cognitive outcomes and major congenital malformations.
Initially regional anesthesia was planned for the patient’s primary cesarean, but new and worsening foot drop suggested a possible AVM in the spinal cord. As neither computerized tomography nor angiography could be done in the setting of pregnancy, arrangements were made to perform an MRI. Unfortunately the VNS was noted to be incompatible with MRI. Uncertainty regarding the presence, size and extent of a spinal AVM led to the decision to pursue general anesthesia during her section. Meticulous blood pressure (BP) control was recognized to be important to prevent rupture of either the known or postulated AVM. An arterial line was placed preoperatively to assist in this BP management. The patient was induced with propofol, fentanyl, labetalol and succinylcholine, after which a smooth rapid sequence intubation was performed. BPs remained stable throughout. A healthy infant was delivered with Apgar scores of 8 and 9. At the end of the surgery the patient was extubated without incident and brought to the recovery room. She experienced a partial-complex seizure on postoperative day 3, but recovered well with her VNS.
1. Pati S, et al: Pharmacoresistant epilepsy: from pathogenesis to current and emerging therapies. Cleve Clin J Med 2010, 77:457-67.
2. Rudzinski LA, et al: Epilepsy: five new things. Neurology 2011, 76(7 Suppl 2):S20-5.
3. Danielsson I, et al: A pilot study of the teratogenicity of vagus nerve stimulation in a rabbit model. Brain Stimul 2009, 2:41-9.
4. Harden CL, et al: Management issues for women with epilepsy-Focus on pregnancy (an evidence-based review): II. Teratogenesis and perinatal outcomes: Report of the Quality Standards Subcommittee and Therapeutics and Technology Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Epilepsia 2009, 50:1237-46.