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A Labor Epidural in a Cerebral Palsy Patient with Spasticity
Abstract Number: SUN-13
Abstract Type: Case Report/Case Series
Cerebral palsy (CP) is a neurologic condition described as an aberrant control of movement or posture that is non-progressive and permanent, appearing in early life because of an injury to the immature brain. The majority of research in CP focuses on it as neonatal sequelae or in the pediatric population, not as a comorbidity of adult patients. A literature review of CP in pregnant patients yielded case reports that suggested a higher risk of failure with regional anesthesia because of spinal deformities and postural and movement defects. One case report suggested that spinal anesthesia could remove inhibition of athetoid movements and trigger a harmful athetotic crisis.
We report a case of a 36yo G1P0 at 39w1d with congenital spastic quadriplegic cerebral palsy and pre-eclampsia without severe features. The patient had presented to OB clinic one week prior to admission for acute non-traumatic left hip pain described as a tight, sharp pain worse with movement, and she was no longer able to bear weight. She claimed she was ambulatory at baseline with contractures of her wrists and hands, though because of choreoathetoid movements, she was unable to write. She denied any known trauma to her hip, stating her pain had started acutely and was not relieved by acetaminophen. She described her pain as 0/10 in severity at rest, yet 10/10 with walking, thus confining her to a wheelchair. An AP hip x-ray film noted pubic symphysis diastasis of 2cm, and she was discharged after an orthopedics consult recommended rest and ice. A perinatal anesthesia consultation was requested to address the possibility of abdominal delivery if the patient was unable to push effectively or tolerate labor.
When the patient was admitted for active labor, she continued to complain of left hip pain that had not changed since last seen. The patient requested an epidural for increasingly painful contractions. There was difficulty in positioning the patient because of her spasticity, but an epidural at L4-L5 was then placed without further complication with an infusion of bupivacaine 0.125% with fentanyl 2 mcg/mL at 10mL/hr. The patient reported resolution of previous left hip discomfort and satisfaction with her pain control, and she progressed to spontaneous vaginal delivery after 10 hours. After epidural removal, she reported return of her severe left hip pain with movement, the same in perceived quality and characterization prior to delivery. On patient follow-up with physical therapy, the patient claimed to be at her ambulatory baseline with resolution of her pain.
Our case supports the notion that while cerebral palsy patients may be at higher risk for block failure, in the absence of a severe spinal deformity, this group of parturients can be effectively managed under epidural anesthesia.
1. Gynaecol Perinatol 2012;21:154-5.
2. Int J Anesthesiol 2006;15(1).