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Analgesia in a parturient with agenesis of the right lung, a solitary right kidney and severe scoliosis with implanted hardware weighing 33kg – A case report
Abstract Number: T-70
Abstract Type: Case Report/Case Series
Pulmonary agenesis is a rare (1 in 10,000) developmental disorder often associated with other congenital anomalies (1). Only two prior case reports involving peripartum analgesia are described in the literature (1, 2). In a pregnant patient, the added metabolic demands of the fetus combined with decreased FRC at term and the restrictive pathology associated with aplastic pulmonary disease present a management challenge. We present the case of a nineteen-year old G1 parturient with agenesis of the right lung and left kidney, severe scoliosis with implanted hardware and congenital short stature.
The patient was admitted at 36+4 weeks gestation for expectant management of preterm labor. The antenatal course was notable for recurrent pulmonary infections. The fetus met criteria for IUGR, however this criteria is not normalized for maternal size.
Intravenous opioids, nitrous oxide and neuraxial analgesic options were all presented to the patient. It was acknowledged that in the setting of thoracolumbar spine instrumentation, case series suggest successful neuraxial anesthesia can only be achieved in approximately two-thirds of parturients (3). The patient initially declined this procedure given concerns for procedure associated discomfort and treatment failure. As such, early labor analgesia was achieved with intermittent fentanyl administration. However, due to hypoventilation and decreased oxygen saturation (SpO2 in the 80s) at peak effect, this strategy was discontinued in favor of inhaled nitrous oxide. This option, however, was inadequate during the active labor.
Citing evidence for cephalopelvic disproportion, refractory labor pain, the potential need for episiotomy, instrument assisted or operative delivery, and the risk of fetal intolerance of labor, the patient, in consultation with her obstetricians, requested neuraxial anesthesia. Despite the patients anatomic anomalies combined spinal/epidural technique (bupivacaine without narcotic) was successfully placed with a single attempt. Shortly thereafter, a viable female neonate (APGARS 9, 9, weight 2,125g) was delivered via NSVD with episiotomy. There were no maternal or fetal complication in the perioperative period.
This case highlights the potential morbidity associated with the use of peripartum opioids in patients with decreased TLC, FRC and restrictive lung disease, and the potential utility of neuraxial techniques despite the presence of severe scoliosis for labor analgesia (3).
1. Sarma K, et al. Anaesthetic management of primagravida with hypoplastic left lung. J AnaesthClinPharmacol 2010; 26(3): 403-406.
2. Babita G, et al. Combined spinal epidural anesthesia for cesarean section in a patient with left lung agenesis. IntJnlObstetAnes 2001; 10: 125-128.
3. Ko JY, et al. Clinical implications of neuraxial anesthesia in the parturient with scoliosis. AnesthAnal 2009; 1930-4.