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Neuraxial anesthesia in an obstetric patient with MELAS syndrome
Abstract Number: SU-43
Abstract Type: Case Report/Case Series
This is a case report of a 35yo G5P2 at 35 weeks gestation with MELAS syndrome (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes) who was admitted for induction of labor secondary to pre-eclampsia. Her past medical history includes benign tachycardia, dysautonomia, Raynaud’s disease, nontoxic multinodular goiter, chronic hypertension now with superimposed pre-eclampsia. The patient was diagnosed after her 16-month-old daughter presented with absence seizures and motor milestone regression. On admission, the patient presented with a blood pressure of 160/94 and heart rate of 95 beats/min. Review of systems was positive for headache, bilateral hearing loss, myalgias and leg cramps worsened by fatigue and stress. Her physical examination was notable for bilateral hearing loss.
Labor analgesia was maintained with a low dose epidural infusion of bupivacaine 0.05% and fentanyl 2 µg/mL. The patient had an uneventful spontaneous vaginal delivery. Both patient and newborn had an uneventful subsequent hospital course and were discharged home on postpartum day three .
MELAS syndrome is a maternally inherited mitochondrial disorder affecting intracellular energy production, and may lead to complications in various organ systems. Concerns regarding the anesthetic management include the use of neuromuscular blockade, risk of malignant hyperthermia, mitochondrial dysfunction from intravenous induction agents, cardiac abnormalities, acid-base and electrolyte imbalances.1
Previous use of regional anesthetic techniques in these patients has been shown to be successful.2,3 Additionally, epidural analgesia for vaginal deliveries may avoid worsening lactic acidosis by decreasing the stress of labor.2,4 Given the concerns over medications commonly used in general anesthetics in the obstetric population, neuraxial anesthesia should be considered for both labor and cesarean deliveries. There is currently limited data regarding outcomes of these techniques in patients with MELAS syndrome, but this case report is consistent with prior cases describing the safety of neuraxial anesthesia in the obstetric population.
1. Gurrieri C, Kivela JE, Bojanić K, Gavrilova RH, Flick RP, Sprung J, Weingarten TN. Anesthetic considerations in mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome: a case series. Can J Anaesth. 2011 Aug;58(8):751-63.
2. Hsiao PN, Cheng YJ, Tseng HC, Chuang YH, Kao PF, Tsai SK. Spinal anesthesia in MELAS syndrome: a case with mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes. Acta Anaesthesiol Sin. 2000 Jun;38(2):107-10.
3. Blair MT, Heard G. Neuraxial anaesthesia in MELAS syndrome. Anaesth Intensive Care. 2011 Nov;39(6):1152-3.
4. Maurtua M, Torres A, Ibarra V, DeBoer G, Dolak J. Anesthetic management of an obstetric patient with MELAS syndrome: case report and literature review. Int J Obstet Anesth. 2008 Oct;17(4):370-3.