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Anesthetic Management of a Parturient with Tetraplegia for External Cephalic Version and Subsequent Cesarean Delivery: A Case Report
Abstract Number: SUN-29
Abstract Type: Case Report/Case Series
Introduction: 85% of patients with spinal cord injury above T6 have autonomic dysreflexia (unopposed sympathetic discharge below injury) (1). It can be elicited by distention of the bladder, colon, or onset of uterine contractions. We present a parturient with severe autonomic dysreflexia from an incomplete C5-7 spinal cord injury for external cephalic version and subsequent C/S.
Case report: A 28 y/o G2P0, 37 1/7 wk female (BMI 28.8 kg/m2) presented with pyelonephritis and category 2 FHR trace for IV antibiotic therapy. PMH included C5-7 incomplete spinal cord injury with quadriplegia, severe autonomic dysreflexia, neurogenic bladder, decubitus ulcers, neurogenic diabetes insipidus, depression, and asthma. She developed FHR decelerations, necessitating expedited delivery and since her fetus was transverse lie, external cephalic version followed by induction of labor was planned. C/S would follow a failed version. After placing a combined spinal/epidural (CSE) (intrathecal bupivacaine 2.5 mg, 5 mcg sufentanil) and gentle abdominal pressure, the FHR dropped. A right radial artery catheter was placed and an urgent C/S commenced using epidural anesthesia. An epidural infusion (bupivacaine 0.125%, fentanyl 2 mcg/mL) provided postoperative analgesia.
Discussion: Uncontrolled autonomic dysreflexia can lead to intracranial hemorrhage, seizures, MI, pulmonary edema, coma and death (2). Severe hypertensive episodes may compromise uteroplacental perfusion but neuraxial anesthesia can blunt hypertensive responses and increase the success rate of ECV (3). Urgent C/S may become necessary (fetal intolerance, placental abruption, onset of labor) so our anesthetic plan consisted of CSE using a small spinal dose of bupivacaine and sufentanil for ECV, reserving the epidural for labor or subsequent C/S. Since spinal anesthesia for C/S may cause severe hypotension, an epidural permits slow titration and minimal hemodynamic fluctuation. One can monitor disappearance of spastic paresis, quality of BP control, and temperature changes to assess neuraxial anesthetic efficacy (4). Pin prick assessment was adequate in our patient. Since no method of anesthesia is completely effective in abolishing autonomic dysreflexia, we placed an arterial catheter and had short acting agents (nitroprusside, nitroglycerin, labetalol, nicardipine, phenylephrine, ephedrine) available to treat BP swings. Neuraxial anesthesia may not be possible in many spinal cord injured patients (spinal stabilization procedures, obliteration or scaring of epidural space) so general anesthesia with the associated risks of aspiration, possible difficult intubation, acute hyperkalemia from succinylcholine, and transfer of medications to the fetus, may be necessary. A low dose epidural infusion minimizes pain and uterine cramping in the postpartum period.
References:1. Anaesthesia 1998;53(3):273-289. 2. J Am Paraplegia Soc 1992;15:171-186. 3. Obstet Gynecol 2011;118:1137-1144. 4. Hippokratia 2006:1;28-33