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SUCCESSFUL MANAGEMENT OF MOYAMOYA DISEASE AND SICKLE CELL DISEASE IN A SYSTEMICALLY ANTICOAGULATED PATIENT UNDERGOING A CAESAREAN DELIVERY
Abstract Number: SUN-62
Abstract Type: Case Report/Case Series
Introduction: Moyamoya disease (MMD) is a rare cereberal vascular disease with progressive occlusion of the terminal internal carotid arteries and the vascular networks that act as collateral pathways. (1) Patients with MMD are at risk for both ischemic and hemorrhagic strokes within the collateral networks (2), and neurological complications have been reported at rate of 6%. (3) Both vaginal and caesarean deliveries are permissible, assuming hypocapnia, hypertension, and hypotension are avoided. (2) We describe a case of a patient with MMD that underwent a successful caesarean delivery.
Case Presentation: A 32 year-old G2P1 presented at 33 weeks in preterm labor. Her medical history was significant for MMD causing a cerebral vascular event in 2009 (no residual deficits) with subsequent external carotid to middle cerebral artery bypass in 2010, and sickle cell disease (SCD) requiring chronic opioids. Two weeks prior, she was diagnosed with a subsegmental pulmonary embolus (PE), and she started on therapeutic lovenox that was continued until one day prior to surgery. An arterial line was placed prior to rapid sequence induction with propofol, remifentanil, esmolol and succhylcholine. She was started on a ketamine infusion and administered interval doses of hydromorphone given her history of chronic opioid use.
Her intraoperative course was complicated by a hemorrhage of 2500 ml, due to atony and suspected focal accreta, that was treated with misoprostol, B-lynch suture, and a Bakri balloon. She received 2 units of both packed red blood cells and fresh frozen plasma during the case, and she was extubated without complication. Her hemorrhage resolved and she was restarted on lovenox on post-operative day one. The ketamine infusion was continued along with a hydromorphone PCA providing excellent pain control in a patient with chronic opioid use. No neurological deficits were noted post operatively, and she was discharged four days after delivery.
Discussion: Anesthetic considerations for parturient with MMD include adequate analgesia and anxiolysis, in order to avoid hypertension, tachypnea, and hypocapnia. Both neuraxial and general anesthesia may be utilized to achieve these goals. Our patient had additional complications of SCD and a recent PE. Her chronic opioid use provided a substantial challenge for pain control in the setting of therapeutic anticoagulation preventing the use of neuraxial techniques. We were able to maintain hemodynamic stability during induction using the short acting medications remifentanil and esmolol, and achieve postoperative pain control with a ketamine infusion and hydromorphone PCA.
References: 1) Komiyama M (1998) Neurosurgery 43: 360-369. 2) Takahashi JC, (2012) Neurol Med Chir 52: 304-310. 3) Weston, E. (2016) Obstetric Medicine 9: 177-180.