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Intrapartum MRI? - Coordinating Care on the Fly
Abstract Number: SUN-63
Abstract Type: Case Report/Case Series
Intro: Neurofibromatosis (NF) is a rare neurocutaneous disorder with two distinct subtypes with different clinical manifestations. NF -1 accounts for 85% of the cases and is characterized by widespread proliferation of neural crest tissue. Manifestations include café au-lait spots, peripheral or central neurofibromas including spinal and pharyngeal lesions, and hypertension. Antenatal imaging is recommended in parturients with NF-1 due to risk of spinal or epidural hematoma after neuraxial placement, even in asymptomatic patients. In the absence of available imaging, providers may be hesitant to proceed with neuraxial placement, even in high risk patients who request labor analgesia. We describe a novel approach to coordinating care in a NF11 patient on labor and delivery without preoperative imaging.
Case: Our patient is a 22yo G3P0 at 31 weeks GA who presented for IOL secondary to pre-eclampsia with severe features (based on blood pressures and platelet values). Medical history included NF-1, SLE with pericarditis and pericardial effusion during her pregnancy that required percutaneous 1L drainage. The patient did not have recent imaging of the spine, however, she did not have neurologic complaints. The patient was receiving magnesium therapy, foley bulb was removed and no uterine contractions were noted on tocodynomometer when the anesthesia service was consulted for labor epidural catheter placement. Fetal heart rate tracing was a category I, maternal blood pressures were normalized and obstetric plan included oxytocin augmentation. After multidisciplinary discussion, it was determined that the patient would benefit from epidural catheter placement, but imaging would be required. Care was coordinated to halt induction and an MRI of the spine was performed emergently. No spinal lesions were noted and the patient received labor analgesia via a combined-spinal epidural catheter placement with an uneventful vaginal delivery.
Discussion: Optimal management of parturients with NF- I includes multi-disciplinary planning and preoperative anesthesiology evaluation as NF may affect the airway and spine. Exclusion of spinal lesions may facilitate neuraxial placement, but this is not always available on day of delivery. Antenatal assessment may be of even more importance for patients who are high risk such as this patient, whose medical history also included SLE with cardiac manifestations, pre-eclampsia with severe features and thrombocytopenia. While obtaining an intrapartum MRI may not seem feasible, a timely discussion with the obstetrician and patient allowed for imaging that influenced anesthetic management. In this case it supported epidural catheter placement. This case highlights that, in the absence of pre-delivery MRI, certain laboring parturients with NF-1 can obtain relevant imaging that influences anesthetic management with proper coordination of care.
1) Esler MD, et al. Br J Anaesth. 2001 Dec;87(6):932-4