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Management of Parturients with Chiari Malformation I: Case Series and Review of Current Literature
Abstract Number: T-53
Abstract Type: Case Report/Case Series
INTRODUCTION AND METHODS
Management of a parturient with known Chiari Malformation I (CM-I) can be particularly challenging. Retrospective chart review of 48 patients, who presented to our hospital from 1996 to 2012 and carried the diagnoses of both pregnancy and CM-I, was conducted. Patients who delivered outside the institution and those who were not diagnosed when they delivered were excluded. A total of 27 patients were identified which led to 46 deliveries.
The diagnosis of CM-I was established in 14 deliveries prior to pregnancy, of which 7 were vaginal deliveries and 7 were cesarean deliveries. Among the vaginal deliveries, 2 were assisted given history of CM-I. Three of the cesarean deliveries were performed based on the recommendation of consulting neurosurgeons. For laboring patients, 4 received epidural analgesia, 1 received combined spinal epidural analgesia, 1 had serial single shot spinal analgesia, and 1 elected and achieved natural childbirth. For patients who delivered via cesarean, 3 received spinal, 1 received combined spinal epidural, and 3 received general anesthesia. There was 1 case of inadvertent dural puncture during placement of an epidural in a patient with history of Chiari decompression and a functional ventricular-peritoneal shunt. Recovery of post dural puncture headache was achieved with an epidural blood patch. A second case developed post dural puncture headache after a combined spinal epidural which was treated with conservative management. No parturient had exacerbation of symptoms during the peripartum course. None of the patients who received general anesthesia had difficult intubation or a complicated course.
Neuraxial technique was performed in about 70% of our cases for patients who had known CM-I diagnoses. There was no reported exacerbation of Chiari related symptoms. Neurosurgical evaluation in these patients prior to labor and delivery is essential even for those patients who had Chiari decompression. Patients with significant signs or symptoms of neural compression are challenging and one could argue that a cesarean delivery with controlled general anesthesia might be a more prudent plan. We advocate for a multidisciplinary team approach of neurosurgeons, obstetricians and anesthesiologists in order to discuss not only the best mode of delivery, but also the safest anesthetic plan. For patients who develop PDPH, EBP is most likely safe and recommended. With novel imaging modalities, better assessment of cerebrospinal fluid flow hydrodynamics might give insight in understanding the pathophysiology of the disease process which may lead to improved management and outcome.
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