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Neuraxial Labor Analgesia In A Parturient With VACTERL Association
Abstract Number: T-43
Abstract Type: Case Report/Case Series
The term VATER association, first coined in 1973 and later expanded to VACTERL association, is an acronym for a group of congenital malformations: involving Vertebral, Anal, Cardiac, Tracheo-Esophegeal, Radial and Limb anomalies. The incidence is less than 1-9/100,000 live births with male preponderance (69.8%). VACTERL association is genetically considered a polytopic change occurring during blastogenesis without any single, unifying etiology. The diversity of the VACTERL anomalies poses a formidable challenge to anesthesiologists. We describe the successful anesthetic management of a parturient in active labor with VACTERL association, who underwent a combined spinal epidural (CSE) technique for vaginal delivery.
A 23-year old primigravida at 39-weeks intra-uterine gestation presented in labor at 3cm cervical dilatation, with complete effacement, requesting labor analgesia. Past medical history included VACTERL association with an imperforate anus and an atrial septal defect, which were both repaired in early childhood. She also had significant dorso-lumbar scoliosis with an extra vertebra. An MRI performed at 14 years age revealed dorso-lumbar scoliosis, an extra thoracic vertebra, and no spinal cord abnormalities. Echocardiography done at age of 21-years revealed mild aortic and mitral regurgitation with a LVEF of 60%. The patient had a BMI of 27 kg/m2, and Mallampati class I airway. With a normal neurologic exam and with her describing a 9 out of 10 pain (0-10 numeric pain rating scale) it was planned to attempt CSE in sitting position despite not having recent neuraxial image to assess the degree of scoliosis. Although, there was significant scoliosis, the epidural space was identified at L3-L4 interspace at depth of 6 cm via a loss-of-resistance to saline technique. Spinal Fentanyl 25mcg was administered followed by patient-controlled epidural analgesia with epidural infusion of 0.1% Bupivacaine and 2mcg/ml of Fentanyl at 6ml/hour with 5ml bolus dose every 20 minutes. The patient had complete pain relief within 3 minutes of the spinal fentanyl. She had an uneventful vaginal delivery 5 hours later requiring only 2 epidural bolus doses.
The rarity of VACTERL association in the obstetric population (only 2 previous case reports in cesarean section patients) coupled with the myriad of systemic malformations mandates a vigilant multidisciplinary approach in the perinatal period. This is the first reported case of a successful and safe neuraxial technique in a laboring patient with the VACTERL association. Despite not having anesthesia involvement in the prenatal period, the importance of a thorough and timely work-up of these patients in the prenatal period cannot be over-stressed to mitigate potential complications especially in more severe cases of the VACTERL association.
1.Benjamin DS, et al. Am J Med Genet A. 2012;158A(12):3087-100
2.Hilton G, et al. Can J Anaesth 2013;60:570-6