A complex case of labor management in a patient with autonomic hyperreflexia due to a C5-6 injury who sustained an unintentional dural puncture during epidural placement
Abstract Number: T 77
Abstract Type: Case Report/Case Series
Autonomic hyperreflexia (AHR), once considered a mortal danger for women with spinal cord injuries (SCI) in labor, may be prevented or ameliorated by early labor analgesia. Though limited, case reports describing this practice in parturients with SCI and concomitant AHR have yielded positive outcomes for mother and baby, thus giving hope to the 2000 women of child-bearing age who sustain SCI each year. Anesthesiologists play a vital role in ensuring the safety of such patients when they become pregnant.
We present the case of a 34 year old, gravida 5 para 0 at 35 weeks gestation, incomplete quadriplegic with SCI at C5-6 from a motor vehicle accident at age 16, who presented with elevated blood pressures and headaches. Labor was ruled out, so it was presumed that she was experiencing symptoms of AHR secondary to kidney stones found on renal ultrasound. Urology was consulted for treatment, and her blood pressure spikes from sympathetic activation were successfully controlled with epidural analgesia.
Her anesthetic management became complicated by an unintentional dural puncture, and subsequent development of a headache. Though her symptoms were characteristic of a spinal headache, the cause of it was confounded by the fact that she had recently presented with headaches associated with AHR. Additionally, the patient had protein in her urine and became thrombocytopenic to 97.000, thus making pre-eclampsia another plausible etiology for her headache (despite the patient’s preexisting proteinuria).
After discussions with MFM, she was induced because of her complicated clinical picture. Epidural analgesia was continued, which adequately controlled her blood pressures during contractions. The obstetricians strongly advised against a Cesarean section due to risk of stroke and other complications with additional stress to her body. Additionally, the patient had an appendicovesicostomy to allow catheterization from her umbilicus, which covered the anterior surface of her gravid uterus. According to her urologists, access to the uterus would involve almost certain damage to her bladder.
The rest of the patient’s labor was uneventful, and she delivered vaginally with vacuum assistance. Her headache persisted two days later, so an epidural blood patch was performed using the in-situ catheter. The patient’s headache resolved almost immediately, and she was discharged after two days.
Despite multiple comorbidities and complications, the patient underwent a safe and successful labor. This is undoubtedly attributed to the discussions that took place about her case among various care providers, including MFM, obstetricians, anesthesiologists, and urologists before she presented to the hospital in labor. She was cared for via a multi-disciplinary approach, and early involvement of the anesthesia team led to close monitoring and frequent communication amongst all parties involved, thus yielding a positive outcome.