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Successful neuraxial anesthesia for cesarean delivery in a patient with severe oral and neck arteriovenous malformations
Abstract Number: T-62
Abstract Type: Case Report/Case Series
Oral and neck arteriovenous malformations (AVMs) can pose significant risks for airway compromise during neuraxial or general anesthesia. AVMs are highflow lesions and have a propensity to bleed, which may be life-threatening. Accelerated growth of these lesions occurs during pregnancy from elevated hormonal levels. Here we present the case of a 24-year-old female with severe oral and neck AVMs who underwent a successful cesarean delivery under neuraxial anesthesia.
A 24-year-old G3P2002 (5’2”, 195 lbs, BMI 35.73 kg/m2) with an estimated gestational age of 39 weeks presented to the labor and delivery unit for a repeat cesarean section. Her past medical history was significant for endoscopic sinus surgery and tracheostomy, with subsequent decannulation. On exam, the patient was obese with a large neck diameter, short thyromental distance, and a Mallampati score of IV. She had significant lingual and lower lip, as well as bilateral neck AVMs. Her most recent MRI demonstrated multifocal airway stenosis at the oropharynx and the larynx secondary to her AVMs.
The patient was taken to the operating room with plans for a combined spinal and epidural (CSE) placement. The difficult airway cart, video laryngoscope and additional anesthesia personnel were present. An otolaryngologist was on standby for an emergent tracheostomy if needed. The CSE was performed without difficulty and the patient underwent a cesarean delivery without complications. A healthy baby girl was delivered. The patient's postoperative course was uneventful and she was discharged home two days later.
Our case demonstrates that a repeat cesarean delivery can be performed safely under combined spinal epidural anesthesia in a patient with severe oral and neck AVMs. Anesthesiologists should be prepared for alternative techniques and emergent airway equipment and personnel should be made available. Accelerated growth of AVMs during pregnancy can put them at risk for ulceration, rupture or hemorrhage. A vascular surgery or otolaryngology consult is essential early in pregnancy, to evaluate lesions and to determine if devascularization or removal of AVMs are necessary. Preoperative imaging and an elective tracheostomy prior to cesarean delivery may be warranted in patients with unstable AVMs or in patients with signs of airway obstruction.
Mushambi MC et al. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia 2015;70:1286-1306.
Chen W et al. Comprehensive treatment of arteriovenous malformations in the oral and maxillofacial region. J Oral Maxillofac Surg 2005;63:1484-8.
Duyka LJ et al. Progesterone receptors identified in vascular malformations of the head and neck. Otolaryngol Head Neck Surg 2009;141(4):491-5.