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An Unexpected Faun Tail when Prepping for Labor Epidural
Abstract Number: SUN-07
Abstract Type: Case Report/Case Series
Introduction: Spinal dysraphism describes a heterogeneous group of disorders of the vertebral arches, spinal cord and meningeal layers. Although the prevalence is relatively high, detailed descriptions of peripartum analgesia and anesthesia methods are limited.
Case: A 38-year-old, gravida 4 para 2, recent Honduran immigrant, with a single intrauterine pregnancy presented in labor at 39 2/7 weeks. She previously delivered two healthy children via uncomplicated vaginal delivery without neuraxial anesthesia. Upon admission, she requested epidural analgesia and during preparation, an area of hypertrichosis was noted extending from the patient’s mid-thoracic to lumbar area (see Image). The patient denied neurological complications at birth or a medical history of spina bifida. A physical exam demonstrated no neurological deficits. A CSE was placed in the L4-5 interspace without complication. Preservative-free morphine 150 mcg and Fentanyl 15 mcg was placed intrathecally, and patient controlled epidural anesthesia (PCEA) with bupivicaine 0.125% at a rate of 6 ml/hr was started following a 6 ml initial bolus. Ninety-minutes after placement, the patient complained of pain. She had an L1 level on the right and no level on the left. The epidural catheter was withdrawn 1.5 cm, infusion rate increased to 8 ml/hr and bupivicaine 0.125% 10 ml bolused, resulting in effective pain control for SVD. A post-partum thoracic MRI revealed previously undiagnosed T7-9 non-fusion of posterior vertebral bodies with partial extension of the thecal sac into the defect. The patient was informed of the findings and discharged postpartum day one. On postpartum day five the patient developed a postdural puncture headache. It resolved at home with conservative measures.
Discussion: Successful neuraxial labor analgesia is possible in select patients with spinal dysraphism. The risk of failure and complications is higher. This patient had 27 encounters with healthcare providers between entry to care and delivery; however, no anomalous findings were documented. The initial prenatal encounter should include a basic back exam for any patient who may require neuraxial anesthesia. Mandatory folic acid fortification in Latin American countries began in 1993. Providers should have a higher index of suspicion for neural tube defects in women born before 1993 from these countries.
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