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Anesthetic Management of Labor in a Patient with Traumatic T3 Paraplegia
Abstract Number: T 50
Abstract Type: Case Report/Case Series
Spinal cord injury in pregnancy can present significant anesthetic challenges. We present a case of a 23-year-old female, with new-onset T3 paraplegia sustained during her pregnancy, who presented in active labor.
A 23 y/o G2P0 female was admitted at 15 weeks gestation after a gunshot wound with the bullet lodged in the T3 vertebra. Her immediate injuries included a left hemothorax, left pulmonary contusion, and complete paraplegia of the lower extremities. Neurosurgery treated her unstable spine injury conservatively with bracing. Anesthesia consult at 23 weeks recommended, after neurosurgical clearance, early neuraxial analgesia to prevent possible autonomic dysreflexia. The patient was then discharged to a rehab facility. After multidisciplinary planning meetings, she was readmitted to our obstetric service at 28 weeks for obstetric care, and began having irregular contractions presenting as back pain and premature rupture of membranes at 33 weeks.
A combined spinal-epidural catheter (CSE) was placed uneventfully, with 2 mg of midazolam for anxiolysis. An epidural solution of 0.125% bupivacaine with 3.33 mcg/mL of fentanyl was run for the next 12 hours without significant hemodynamic instability. Breakthrough back pain was treated with 5-8cc of 0.25% bupivacaine. She had an uncomplicated forceps-assisted vaginal delivery. Patient recovered well and was discharged to a rehab facility for further treatment.
Autonomic hyperreflexia (AH) is caused by loss of hypothalamic control of sympathetic reflexes. AH is common with spinal cord injury above T6, and manifests as hypertension, bradycardia, tachycardia, cardiac arrhythmias, or respiratory distress. Visceral or cutaneous stimulation below the level of the spinal cord lesion are common precipitants (1). During labor, untreated AH may lead to fetal distress, maternal intracranial hemorrhage, hypertensive encephalopathy and death. (2) Both undiagnosed labor with precipitous delivery and preterm labor are common. Labor is often diagnosed because of unexplained AH.
We placed a combined spinal epidural (CSE) for labor analgesia because this technique would provide both rapid analgesia and verification that the epidural was in the correct space (3). Assessing sensory level of neuraxial anesthesia can be impossible. Our patient had chronic back pain that allowed her to report contractions. We also used a high concentration of epidural medications to provide a dense block to prevent AH. In the event that the patient did develop symptoms of AH, we had planned to place an arterial line and treat with hydralazine and nitroprusside. In conclusion, this patient had a safe outcome following labor as a result of careful planning with a multidisciplinary team and early initiation of labor analgesia.
1. Kuczkowski, et al. Arch Gynecol Obstet 2006;274:108-12.
2. Strowonski, et al. Austral New Zeal J Obstet Gynaecol 2008;48:485-91.
3. Norris. IJOA. 2000;9:3-6.