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Peripartum Management of A Parturient with Neuromyelitis Optica
Abstract Number: F-55
Abstract Type: Case Report/Case Series
We report a case of 34 year-old woman, gravida 4 para 1, currently at 27 weeks gestation, with a history of neuromyelitis optica (NMO, also known as Devic’s disease) who presented for an obstetric anesthesiology consultation with regard to her anesthetic management for her upcoming delivery. Her body mass index was 43 with Mallampati class 2-3 airway. Prior to her diagnosis of NMO, she had a Cesarean delivery in 1999 for non-reassuring fetal heart tracing under epidural anesthesia. Her first major NMO flare was in 2004 when she presented with paralysis and respiratory failure requiring a tracheostomy and ventilator-dependence for 6 months. Having failed steroid treatment, she had been maintained on rituximab therapy. Her last paralytic flare was in 2009. Since her current pregnancy, her neurologist has switched her management to monthly intravenous immunoglobulin administration. She still has occasional residual tingling in her lower extremities (left worse than right), with occasional balance issues, lower extremity weakness, and chronic mid back pain and spasms. However, she strongly desires a trial of labor for her current pregnancy. We counseled her about the options of epidural and general anesthesia. A team approach is currently underway between her obstetricians, neurologists, and anesthesiologists regarding her anticipated delivery in March 2012. A complete and comprehensive review of the anesthesia management for this case will be available at the SOAP meeting in May 2012.
The anesthetic plan for patients with NMO is controversial. While either regional or general anesthesia would be suitable for potential autonomic dysfunction associated with the disease, the available literature cannot pinpoint a direct cause-effect relationship between the flare of myelitis and anesthesia technique. In addition, the stress from labor and delivery, together with rapid hormonal changes postpartum, are likely to increase the risk of an exacerbation. There have been limited case reports of pre-existing NMO during pregnancy. While utilization of epidural anesthesia in the setting of transverse myelitis has been reported, it could increase the difficulty of monitoring for any deterioration of the patient’s neurological status. Transverse myelitis has also been reported to develop after general anesthesia. We suggest that a team care model would be most suitable for such cases to balance the respect for the patient’s autonomy and the physician’s beneficent duty.
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