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Neuraxial Analgesia in a Parturient with Marfan Syndrome (MF) and Dural Ectasia (DE) – A Matter of Informed Choice
Abstract Number: T 78
Abstract Type: Case Report/Case Series
Neuraxial anesthesia (NA) is endorsed in parturients with MF if aortic dilation is present, as effective pain relief reduces the risk of aortic dissection/rupture. This population is known to have a high incidence of DE which includes ballooning of the dural sac, along with protrusion of dura outside the spinal canal. DE thus presents a conundrum in patients having NA, increasing the risks of both failed NA and inadvertent dural puncture. We report our experience with providing epidural analgesia to an MF parturient with known DE.
A 30yo G3P1011 at 38wks EGA was seen in clinic to discuss labor analgesia. She had known MF; and was a 69 in, well-developed female with arachnodactyly and joint laxity. Medical history included pneumothoraces requiring sclerotherapy. She was taking pindolol 10 mg bid and had no allergies. Of note, she had an LP for a meningitis workup followed by development of a post-dural puncture headache (PDPHA). The PDPHA was unrelieved by blood patches, and she underwent 2 laminectomies (L3-5) for attempted dural repair, during which she was diagnosed with DE. She had a recent TTE which demonstrated a LVEF of 65%, mild MR, and a normal aortic diameter. Even after discussion of possible dural injury and block failure, she still opted for epidural analgesia. She presented in active labor 3d later with a cervical dilation of 4 cm and requesting epidural placement. The space was located using a 17G Weiss needle using an LOR technique at T12-L1 (just above her surgical scar) and the epidural catheter was inserted. After a negative test dose, the block was induced with divided doses of 0.25% bupivacaine, and an infusion of 0.2% ropivacaine was started. She had good labor analgesia for 4.5hrs, but developed a unilateral block that responded minimally to repositioning, catheter withdrawal, or repeated 5 ml boluses of 0.25% bupivacaine. As the patient was at 7 cm dilation, and reported some relief from the largely unilateral block, we agreed to maintain the epidural infusion and with supplementation with parenteral analgesics. She delivered vaginally 4hrs later without complication.
It was decided that an epidural would provide optimal labor analgesia in this patient as it would provide both excellent analgesia for labor, and could provide operative anesthesia for a cesarean section. It was thought prudent to avoid CSE and SAB anesthesia in a patient who already suffered from a breech in dural integrity. Additionally, we were aware of documented inadequate intrathecal blocks in this patient population. As previously reported (1), this patient had received labor analgesia with a remifentanil PCA during her first pregnancy, because of the perceived risks, which resulted in an unsatisfactory outcome in the patient’s opinion. For the second pregnancy the patient was willing to undergo the risks of NA in an effort to have a less painful labor.
1. SOAP 2011, Abstract A-66.