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Is a neuraxial technique contraindicated in the parturient with a history of cerebral arteriovenous malformation?
Abstract Number: SUN-47
Abstract Type: Case Report/Case Series
Cerebral arteriovenous malformations (AVM) are a rare abnormality of arteries and veins that pose a risk of rupture and hemorrhage. We present a case of a parturient in labor with a history of ruptured AVM.
A 21-year-old G2P0 with a history of resected temporal hemorrhagic AVM at the age of 7 presented late for prenatal care. She had no residual neurological symptoms and cerebral angiography 3 months after resection showed no persistent vascular abnormality. Her grandmother and uncle had cerebral AVMs, but there was no personal/family history of epistaxis or telangiectasias.
Neurosurgery stated that while she did not have a clear contraindication to Valsalva, the possibility of recurrent AVM could not be ruled out without imaging. The obstetric anesthesia service determined that given the family history of AVMs, there was a possibility of a spinal AVM due to hereditary hemorrhagic telangiectasia (HHT). Given these concerns, a non-contrast MRI of the spine/brain was scheduled.
Prior to the MRI, she presented in labor and general anesthesia was recommended for her elective cesarean, however she wanted to be aware during the birth and elected to labor. A remifentanil PCA was ordered and IV nalbuphine was administered for pain control. Her labor progressed quickly and she delivered a healthy male infant.
The prevalence of cerebral AVMs is less than 0.1%, and most are sporadic with a single malformation(1). A rare cause of cerebral AVMs is HHT, which predisposes patients to multiple pulmonary, gastrointestinal, and spinal AVMs. In the absence of imaging, an important question arose in the management of this parturient: could she safely have a vaginal delivery and neuraxial anesthesia? Given that the literature does not support an increased rate of rupture of cerebral AVMs in pregnancy, a cerebral AVM was not a contraindication to labor(2).
Even though the likelihood of HHT was low, a neuraxial technique was not offered given the possibility of a spinal AVM. In retrospect, this reasoning may have been flawed. A real risk of spinal AVM (1%) exists in HHT, but the risk of multiple pulmonary AVMs (50%) is much higher(3). Furthermore, the risk of difficult intubation is increased during pregnancy and labor(4). In this case, the risks of general anesthesia probably outweighed the risks of a neuraxial technique.
This case presents an important lesson in the decision making process for neuraxial vs general anesthesia during pregnancy. Although there may be relative contraindications to a neuraxial technique, contraindications to general anesthesia may outweigh those risks. Furthermore, spinal anesthesia has been previously administered safely in a parturient with HHT(3). Regardless of the diagnosis, this case teaches us that we should always consider the risks and benefits of both neuraxial and general anesthesia.
1. Brain 2001.
2. Neurology 2014.
3. Eur Rev Med Pharmacol Sci 2012.
4. Can J Anesth 2011.