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Spontaneous epidural abscess during pregnancy
Abstract Number: SU-02
Abstract Type: Case Report/Case Series
The typical presentation of an epidural abscess includes fever, back pain and neurologic deficit.1 However, this triad is not always manifested so clearly.1 Our patient experienced only one of these symptoms underscoring the importance of a high index of suspicion and urgent imaging when an epidural abscess is suspected. We present a case of a woman at full term with a history of drug abuse and hepatitis C who developed an epidural abscess causing paralysis requiring urgent delivery secondary to active labor followed by a decompressive laminectomy. She had a viable infant but did not regain function in her lower extremities.
A 31 yr old G4P3 woman at 37 1/7 weeks presented to an outside hospital with acute onset weakness in her bilateral lower extremities. Her history included hepatitis C, drug abuse, and three prior cesarean deliveries (CD). MRI revealed a 4x1x1cm epidural mass at T9-T12 with cord compression. On arrival to our ICU she had 0/5 strength, decreased sensation in bilateral lower extremities and no rectal tone. During her evaluation she was noted to be in active labor and, given her history of multiple prior CDs, the decision was made to proceed with CD and BTL followed by a laminectomy. She had a normal BMI, airway and normal heart and lung exams. She was brought to the OR and a RSI was performed with lidocaine, fentanyl, propofol, and succinylcholine. An infant was delivered with APGAR scores of 7 & 9. He was positive for cocaine & opiates. Placement of the arterial line was difficult but was achieved prior to the laminectomy. The patient was then turned prone and underwent a T10-T11 hemilaminectomy and decompression. She tolerated the procedure well, was extubated, and transported to the ICU. She was discharged on POD 12 to a rehab facility. To our knowledge, she has not regained motor function.
While the incidence of substance abuse during pregnancy is relatively high at 5.2%,(2) spontaneous epidural abscesses during pregnancy are extremely rare.3 Risk factors include IV drug use, alcoholism, diabetes, infection and immunosuppression.3 When our patient initially presented, it was evident she suffered a major neurologic insult however these patients can simply present with back pain & fever. Thus it is important to have a high index of suspicion particularly if other risk factors are present. Our patient went into active labor with variable decelerations 15 minutes before proceeding to the OR and while we were concerned that delaying the laminectomy may cause permanent paralysis, we were more concerned for intra-operative uterine rupture and IUFD. Ultimately, we decided to proceed with delivery followed by the laminectomy. Identification of an epidural abscess during pregnancy may be more difficult but rapid diagnosis followed by definitive treatment is critical.
1. N Engl J Med. 2006; 355:2012-20.
2. Med Clin North Am. 1997; 81:979.
3. Obstet Gynecol. 2010; 116:498-501.