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Management of a Parturient with Neurofibromatosis Type 1
Abstract Number: T-56
Abstract Type: Case Report/Case Series
Neurofibromatosis Type 1 (NF-1), an autosomal dominant disorder with multiorgan system manifestations, can have significant implications for both general and neuraxial anesthesia. We present a case of a 35 year-old G1P0 with NF-1 and multiple asymptomatic cervical and lumbar lesions; in addition, she was anti-coagulated for Factor V Leiden heterozygosity and a unilateral internal carotid stenosis. She had an asymptomatic C2-3/3-4 mass at the neural foramina extending into the spinal canal and bilateral lumbo-sacral neurofibromas. She otherwise had diffuse stable lower extremity neuropathy. Specific anesthetic concerns included possible progression of her lumbar nerve root lesions and anticoagulation precluding placement of a neuraxial block, particularly the “blind” threading of an epidural catheter, and the vulnerability of her cervical spine during head manipulation during general anesthesia.
A multidisciplinary team of neuro-oncologists, OB Anesthesiologists and obstetricians discussed plans for anticipated vaginal delivery but ultimately, we felt that repeat imaging was necessary to guide the anesthetic plan. She underwent an MRI which showed a stable cervical spine lesion and a new finding of an epidural hematoma at L3-4, presumed to be the result of a bleeding neurofibroma. As there was no apparent cord compression or new neurologic symptoms, her LMWH was stopped and she was observed. She subsequently delivered a healthy newborn baby girl via vacuum-assisted vaginal delivery (indication: fetal bradycardia). She was not considered to be a candidate for a spinal or epidural and therefore received Fentanyl PCA.
This case highlights obstetric anesthetic implications of neurofibromatosis and the benefits of antepartum obstetric anesthesia consultation.
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