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Anesthetic Management of a Parturient with Spina Bifida Meningomyelocele
Abstract Number: SAT-84
Abstract Type: Case Report/Case Series
Introduction: The incidence of neural tube defects is approximately 1/1,000 with spina bifida being the most common. Multiple types of spina bifida can occur and are classified according to severity. Spina bifida meningomyelocele is one of the most severe forms in which an unfused portion of the vertebral structure allows the protrusion of the spinal cord and meninges. Typically, the spinal nerves that are involved are damaged manifesting clinically as: paralysis or reduced ambulation, loss of bladder or bowel control, sensory deficits, and deformities of the lower joints and limbs.
Case: A 33 y/o G1P0 presented at 34w0d with pre-eclampsia with severe features. Her past medical history was significant for spina bifida meningomyelocele, immobility (wheelchair bound), neurogenic bladder, scoliosis (s/p Harrington rod placement between T2-L4), morbid obesity, short stature, chronic HTN, and previous reconstructive hip surgery. Her pregnancy was complicated by parvovirus infection in the second trimester and recurrent UTIs. Due to her body habitus it was unlikely she could deliver vaginally and she was consented to deliver via c-section. In addition to her back deformity, the patient expressed extreme anxiety and a low pain threshold, as well as great discomfort lying flat. Prolonged surgery was expected due to her prior abdominal and urological procedures, making a CSE or epidural our only options for neuraxial anesthesia. A high likelihood for inadequate epidural spread made this choice less ideal. While a spinal catheter was considered, if PDPH occurred, she would not be offered a blood patch due to her hardware. Ultimately, the decision made in consultation with the patient, obstetrician, and consulting teams (urology and general surgery) was for induction of general anesthesia for cesarean delivery. She was intubated without difficulty and a vigorous neonate was delivered. The patient suffered no anesthetic complications and her postoperative course was uneventful.
Discussion: Significant improvements in the surgical and medical management of spina bifida over the last few decades have resulted in many of these patients living to child bearing age. There is limited literature discussing labor analgesia in these women and because of this, no specific guidelines exist. Recommendations are based on case reports such as ours. Neuraxial anesthesia can be attempted, but most case reports highlight the unpredictable nature of a block in this patient population. If neuraxial anesthesia is attempted, it is recommended to be placed above the level of the lesion, making imaging of the spine crucial. While general anesthesia is not without its inherent risks in obstetric patients, we considered it to be the most conservative management of our patient.