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Anesthetic Management of a Laboring Patient at High Risk for Neurological Catastrophe: Call-Fleming Syndrome
Abstract Number: T 74
Abstract Type: Case Report/Case Series
We present a case report of a pregnant patient with a recent diagnosis of Call-Fleming syndrome who underwent labor induction and had spontaneous vaginal delivery with a combined spinal epidural (CSE) anesthesia. While the phenomenon of reversible cerebral vasoconstriction syndrome (RCVS) has been discussed with regards to the postpartum period, to the best of our knowledge, it has not previously been reported in a laboring patient.
24 y/o G5P2 woman with history of migraine headaches presented at 34 weeks gestation in OB clinic with complaints of severe, sudden onset "thunderclap" headache and left-sided weakness. Aneurysmal subarachnoid hemorrhage was excluded by imaging. MRA demonstrated a few areas of severe stenosis of intracranial vessels. Call-Fleming syndrome was suspected and confirmed with subsequent serial trans-cranial Dopplers. The patient was placed on verapamil and levetiracetam. Two weeks later, the OB team decided to induce the patient’s delivery due to decreased fetal movement/oligohydramnios. Patient was still reporting severe headache although her transcranial doppler showed no vasospasm. Though the neurology team suggested c-section delivery as the safest option, the anesthesia team believed vaginal delivery after neuraxial anesthesia would provide the least fluctuations in hemodynamics, which would be optimal in this patient. The multidisciplinary team proceeded with the plan for vaginal delivery. During early labor while the patient was fairly comfortable, CSE was placed with the spinal medication containing minimal local anesthetic (0.5mg bupivacaine), 25mcg of fentanyl, and 0.3mg of preservative-free morphine. An infusion of bupivacaine 0.1% and fentanyl 2mcg/ml was started at 6ml/hr. No test dose was given. The patient's blood pressure was monitored via A-line. She required 2 epidural boluses of fentanyl 50mcg and 1 bolus of 0.125% bupivacaine (10ml) to maintain adequate pain control. A healthy baby was delivered by vacuum extraction after 5 hours of labor.
RCVS was recognised recently as a separate syndrome and combined a group of previously described diseases (Call-Fleming syndrome, benign angiopathy of the CNS, migrainous vasospasm, etc..) It is characterized by multifocal narrowing of the cerebral arteries that resolves over days to weeks. Although the vasospasm is reversible and temporal, it disrupts normal perfusion of the brain and puts the patient at risk of developing ischemic or hemorrhagic stroke. Pain, anxiety, stress, fluctuations in blood pressures, valsalva and sympathomimetic medications which are all common and tolerated during normal labor and delivery, can become life-threatening for the parturient with RCVS and places her at a high risk of neurological catastrophe. We believe that if the obstetrical situation permits, NSVD with a CSE anesthetic dosed with high narcotics/low concentration local anesthetics is preferable for hemodynamic stability.