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Successful Spinal Anesthesia in a Parturient Patient with Transverse Myelitis.
Abstract Number: F-78
Abstract Type: Case Report/Case Series
Introduction: Transverse Myelitis (TM) is a rare demyelinating syndrome sharing characteristics with Multiple Sclerosis (MS) in which affected patients manifest muscle weakness, sensory disturbances and autonomic dysfunction. Neuraxial anesthesia in patients with TM remains controversial mainly because of its rarity and the paucity of literature. We present the first case report of a parturient with TM undergoing a cesarean section (C/S) using spinal anesthesia without a post-operative exacerbation of neurological symptoms.
Case Report: A 35-year old G15P6 female presented at 39 3/7 weeks gestation with ROM and fetal breech position. Past obstetrical history included 5 vaginal deliveries and one C/S for a non-reassuring fetal heart tracing at 32 weeks, all using epidural anesthesia. Her medical history was significant for TM at age 2 with residual weakness in both lower extremities, followed by intermittent exacerbations requiring prolonged hospitalizations and inpatient rehabilitation; the last was 4 years ago. A repeat C/S under spinal anesthesia was planned as a neurology consultation confirmed she was without clinical signs of acute TM. Spinal anesthesia was placed at L3-L4 using 15mg of hyperbaric bupivacaine 0.75%, 200mcg hydromorphone and 10mcg fentanyl; the infant was delivered uneventfully with APGARs of 8 and 9. Immediately following delivery, uterine atony resulted in significant post-partum hemorrhage and prolonged hypotention. Multiple pharmacologic interventions with uterotonics met with little success. Limited surgical hemostasis was obtained and our patient received 8 uPRBCs, 6 uFFPs and 5L crystalloid for an estimated blood loss of 5.5L. Ultimately, she required uterine and iliac artery embolization postoperatively. She was discharged home on post-op day 4 without further complications or neurologic compromise.
Discussion: Historically, anesthesia providers have been hesitant to perform spinal anesthesia for patients with demyelinating disorders. It is postulated that local anesthetics may be neurotoxic to already demyelinated neural fibers in patients with TM or MS and may lead to exacerbation of clinical symptoms(1). In fact, diagnosis of TM has been reported following spinal and CSE analgesia although direct causality has not been consistently established(2). Our patient had a normal recovery despite severe blood loss and hypotension, which could have worsened her disease process through a vascular insult. Our experience suggests spinal anesthesia might be a safe option in patients with TM and significant risk factors for general anesthesia. The decision to perform neuraxial anesthesia in these patients should be made on a case-by-case basis. Here, early planning and close communication with an integrated team of Anesthesiology, Neurology and Obstetrics were essential for a safe and effective anesthetic.
1. Int J Obstet Anesth 2010;19:98–101
2. Jha S, Kumar R. Neurol India 2006;54:425-7