Combined Spinal Epidural for Parturient with Polymyositis
Abstract Type: Case Report/Case Series
Abstract- Polymyositis disease(PD) is an uncommon disease with little discussion in the obstetric anesthesia literature. We describe the use of a combined spinal epidural(CSE) for scheduled cesarean section (CS) for a patient with PD. Case-28 year old G2P1 female presenting at 37.2 weeks for a primary lower transverse CS for fetal myelomeningocele. Patient had a past medical history including PD, Raynaud's disease(RD),and Sjogren’s syndrome (SS). Her first flare of PD was in her early teens. Her PD was limited to her upper extremities. She had been on prednisone 10 mg daily since 13 weeks for PD flair. Otherwise, history and exam were within normal limits. The decision was made to preform an CSE. A low dose spinal was place of 7.5 mg of hyperbaric bupivacaine and an epidural catheter was placed with 5 ml of 2% lidocaine. The patient required a stress dose of steroids and 80 mcg of phenylephrine prior to surgical incision. The rest of the surgery proceed without issue and no other vasopressors or analgesics were needed. Normal return of muscle function was noted on postoperative exam. Discussion-PD is a multi system disease which has an unknown etiology and presents as an inflammatory myopathy(1). PD has a prevalence of 10 per million and an annual incidence of 5.5 per million (2). Muscle weakness is usually in the proximal skeletal muscle including upper extremity, neck, shoulders, and hips. Specific concerns for anesthesia include pulmonary and cardiac systems. There is an increase risk of aspiration, pneumonia, and ventilatory insufficiency due to weakening of pharyngeal,respiratory, and gastric muscles. A common finding is a chronic aspiration pneumonitis. Heart block secondary to muscle atrophy has been described1. Pregnancy is a known trigger for first time presentation however, it is not always a cause for worsening if PD is present. There is controversy regarding neuromuscle blockers(NMB) and PD. Some texts advocate that the response to nondepolarizing muscle relaxants and succinylcholine are normal in patients with PD (1) were others say PD may cause an atypical reaction to both depolarizing and nondepolarizing drugs(2). Anesthetic management should include review of cardiac and pulmonary workups and probable avoidance of general anesthesia. While CSE are toted as an appropriate method to deliver anesthesia no case reports of this type of anesthesia were available. Conclusion- PD patients are at risk for aspiration and have questionable response to NMB. Literature suggest CSE as an reasonable anesthetic in PD and this case report supports the use of CSE in the obstetric patient with PD.
1 Stoelting, Robert K., Roberta L. Hines, and Katherine E. Marschall. Stoelting's Anesthesia and Co-existing Disease. 6th ed. Philadelphia: Churchill Livingstone/Elsevier, 2012.
2 Chestnut, David H. "Chapter 40." Chestnut's Obstetric Anesthesia: Principles and Practice. 4th ed. Philadelphia: Mosby/Elsevier, 2009.