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Pushing Boundaries in Obstetric Anesthesia: Blind vs. Ultrasound-Guided Epidural Placement in a Marfan Syndrome Patient
Abstract Number: F 55
Abstract Type: Case Report/Case Series
Introduction: We present the case of a parturient with Marfan syndrome (MFS) and prior scoliosis correction surgery. Following a failed epidural, an ultrasound (USG)-guided technique resulted in a successful epidural catheter (EC) placement and forceps-assisted vaginal delivery, with patient hemodynamic stability throughout labor.
Case Report: An 18-year-old G1 presented at 38 weeks gestation for labor induction. She had MFS, aortic root dilation, and Harrington Rod placement and removal. Surgical reports were unobtainable; however, the patient remembered her neurosurgeon stating that epidural anesthesia was possible. By transthoracic echocardiography, the aortic root at the sinus of Valsalva was found to be 3.8 cm. The obstetric plan was forceps-assisted vaginal delivery to avoid second stage pushing. An arterial line was placed. A midline epidural performed blindly at the L3-4 level failed to provide analgesia. Though the L3-4 interspace felt adequate on palpation, good tissue demarcation could only be identified with USG at L2-L3 (Figure 1). The EC was replaced at L2-3. After 10 hours of labor, a low forceps-assisted vaginal delivery was performed. The patient had good pain control, and remained hemodynamically stable throughout her hospital course.
Discussion: Scoliosis, a major Ghent diagnostic criterion, occurs in 60% of patients with MFS.(1) Compared to idiopathic scoliosis, scoliosis correction in MFS involves extensive spinal level fusions.(2) Dural ectasia, generally from L5 to S2, is associated with absent posterior epidural fat pad with bulging of the dural sac that occur in 95% of MFS patients.(1) MRI exam in 307 patients with scoliosis showed a mean epidural space width < 1mm in the concave side.(3) Ultrasound guidance was necessary to identify an optimal intervertebral space for successful provision of epidural analgesia in this patient. While aortic root dissection (associated with aortic root > 5 cm) was unlikely, our goals of hemodynamic stability and excellent pain control required successful epidural analgesia.(1)
1.Shirley ED,et al.Marfan syndrome. J Am Acad Ortho Surg 2009;17:572-81
2.Gjolaj JP,et al.Spinal deformity correction in Marfan syndrome versus adolescent idiopathic scoliosis: Learning from the differences. Spine 2012;37:1558-65
3.Liljenqvist UR,et al.Analysis of vertebral morphology in idiopathic scoliosis with use of magnetic resonance imaging and multiplanar reconstruction. J Bone Joint Surg Am 2002; 84:359-68