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Parturients with Chiari Malformation – A 19-Year Review of Experience at the Brigham and Women’s Hospital
Abstract Number: F-40
Abstract Type: Original Research
Background: In the recent years, we found an increased number of patients with Chiari Malformation (CM) coinciding pregnancy. Given the complexity of the condition, limited literature and potential impending neurological sequelae from potential complications of untoward neuraxial techniques, anesthetic approaches to these patients can be strenuous. We conducted a retrospective review of the anesthetic processes of parturient with CM at our institution.
Methods: Retrospective chart review of female patients who carried diagnoses of both pregnancy and CM at the Brigham and Women’s Hospital from 1996 to 2015 have been performed.
Results: Ninety-four patients with CM diagnoses were identified from 1996 to 2014, who made total 108 deliveries. (We will complete the review of the data for the year of 2015 by the time of the SOAP meeting.) In 28 patients with 54 deliveries, first labor and delivery preceded the diagnosis of CM. The average size of cerebellar tonsil herniation was 9.6±4.9mm. For this group of patients, 8 spinals, 26 epidurals and 3 combined spinal epidurals (CSEs) were performed for 34 vaginal and 20 caesarean deliveries (CDs). Most common causes for CDs were failure to progress, non-reassuring fetal tracing and breech presentations. There were total 48 deliveries after the diagnoses of CM type I (CM-I) were made, among which 1 natural child birth (NCB), 8 spinals, 21 epidurals, 4 CSEs and 5 general anesthesia (GA) were performed for 30 vaginal and 18 CDs. GA was applied to patients with neurological symptoms or signs of hydrocephalus/syringomyelia. 8 patients who received decompression operations made 12 deliveries afterwards, for which 1 NCB, 1 accidental continuous spinal catheter, 1 spinal, 7 epidurals were performed for 9 vaginal and 3 CDs. No severe anesthesia related complication was found.
Discussion: This retrospective study provides a large case series of parturient with CM. CM is a complex neurological condition that requires case-by-case review before any specific anesthetic plan is chosen. Recent development on neuroimaging has provided more insights of this condition. Our data and practice support that parturient with asymptomatic CM-I condition are general safe to receive neuraxial technique for labor analgesia and anesthesia. An algorithm for clinical management of parturient with CM is proposed by the authors. Prenatal anesthesia consultation is a very practical method to form teamwork around complicated patient by linking anesthesiologists with obstetricians and neurosurgeons/neurologists, from which a safe anesthetic and obstetric approach to individual patient can be developed.
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