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Chronic Inflammatory Demyelinating Polyneuritis in Pregnancy, a Case of Patient-Controlled Epidural Analgesia
Abstract Number: SAT-71
Abstract Type: Case Report/Case Series
Chronic inflammatory demyelinating polyneuritis (CIDP) is an acquired inflammatory disorder affecting peripheral nerves (1). CIDP is characterized by impaired sensation, symmetrical limb weakness, absent or diminished deep-tendon reflexes, and demyelination on nerve-conduction studies. We discuss a case of patient-controlled epidural analgesia (PCEA) in a 30-year-old, primigravida undergoing treatment with IV immunoglobulin (IVIG) for active CIDP symptoms.
Our patient’s initial symptoms consisted of difficulty going up and down stairs, generalized muscle cramps, and b/l lower extremity paresthesias. At 22-weeks gestation she began experiencing unprovoked falls and increased pain and cramping in her arms and hands. She was admitted at 24-weeks and received IVIG 2g/kg over 5 days; some neurologic improvement was noted at discharge. Our patient was admitted at 5 week intervals for additional IVIG. She reported no more falls after therapy.
At 39 weeks, labor was induced for thrombocytopenia, platelet count 79x10^9/L. Two units of pooled platelets were transfused with a repeat count of 122x10^9/L. At 5-cm dilation, an epidural catheter was placed at the L3-L4 interspace. PCEA was initiated with an infusion of 0.125% bupivacaine + 1.5mcg/mL fentanyl at a rate of 8-mL/hr, patient initiated bolus of 5-mL, and lockout of 10 minutes. Twelve hours after initial placement, she complained of inadequate pain relief and the epidural was replaced at L4-L5. Nine hours later she had an uncomplicated vaginal delivery and was discharged on POD #5. Follow-up at 2 months revealed no new or progressive symptoms.
CIDP is an acquired condition affecting the peripheral nervous system, with a prevalence of about 1-2 per 100,000 adults. Symptoms include impaired sensation, absent or diminished deep tendon reflexes, paresthesias in the hands and/or feet, and symmetrical limb weakness. Diagnosis is based on these symptoms, demyelination on EMG, and greater than 2 month duration of illness. Pathogenesis is thought to be autoimmune related. Effective therapies include IVIG, plasma exchange, and corticosteroids. 60 to 80% of patients show improvement with these treatments.
There is little experience with administration of neuraxial anesthesia in patients with CIDP. What concentration of local anesthetic and duration of exposure is safe? A single case report describes PCEA analgesia in a laboring parturient (2). Her epidural was in place for only five hours and the analgesic mixture was different than ours (0.1% ropivacaine + fentanyl 2mcg/mL). Despite a much longer exposure to epidural local anesthetic (21 hrs), our patient did not develop an exacerbation of CIDP symptoms after delivery or 2 months later. This case suggests that prolonged contact with a dilute solution of epidural local anesthetic may be safe as well.
(1) Dyck PJ, et al. Mayo Clin Proc 1975;50:621-37
(2) Velickovic IA, et al. Reg Anesth & Pain Med 2002;27:217-1