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Anaesthetic management for an elective cesarean delivery in a parturient with Still’s disease
Abstract Number: F5C-6
Abstract Type: Case Report/Case Series
Introduction: Juvenile idiopathic arthritis or Still’s disease is a heterogenous group of inflammatory arthritidies that first appears in childhood. This can result in extensive arthropathy when women reach child-bearing age, complicating pregnancy and limiting options for delivery.
Case Report: A 37 year old primiparous woman presented for elective caesarean delivery after late transfer of care. She was 38+5 weeks gestation and had a background of seronegative Still’s disease, with polyarticular involvement. All major joints of the upper and lower limbs were affected, she had fixed contractures of her elbows and knees, scoliosis and fusion of the cervical spine. She had undergone four previous surgeries to her knees that enabled her to sit comfortably and mobilize independently with a wheelchair. Two of these surgeries had been performed under spinal anaesthetic and two were performed under general anaesthesia with awake fibreoptic intubation. She was 155cm tall and weighed 49kg at booking increasing to 55kg on admission. Pregnancy had progressed normally but she had experienced breathlessness from 35 weeks onwards that was worsening on exertion. She had good mouth opening but reduced jaw slide and was Mallampati 3. She expressed a desire to be awake for delivery.
Focused echocardiography revealed a well-filled hyperdynamic heart with grossly normal LV and RV function. Ultrasound of her spine was also performed to aid in delivery of regional anaesthesia. Severe scoliosis was confirmed but the space was identified at 4.5-4.9cm and the position was marked. A combined spinal and epidural (CSE) was chosen and the L3/4 space identified at 5cm with a saline loss of resistance technique on the second pass. 11.5mg of heavy bupivacaine and 300mcg diamorphine was injected intrathecally via a needle through needle technique. A cold block to T4 was achieved at 10 minutes and surgery was able to proceed. Block recession was noted after 30 minutes, requiring a further 50mg bupivacaine via the epidural route to enable surgical closure. No further surgical complications were noted and she was discharged 3 days later.
Discussion: Neuraxial anaesthesia is challenging in these patients who are known to be at increased risk of anaesthetic complications. The use of bedside ultrasound enabled us to provide safe regional anaesthesia without requiring invasive monitoring. Rapid elimination of cardiac involvement and real-time spinal imaging optimized our management and helped avoid an awake intubation. Due to unexpected rapid offset of the spinal anaesthesia, we would recommend a CSE for management of similar cases.
1. Ehrmann Feldman D et al. Post partum complications in new mothers with juvenile idiopathic arthritis: a population based cohort study. Rheumatology 2017; 56(8): 1378-85
2. Poppat MT et al. Awake fibreoptic intubation following failed regional anaesthesia for Caesarean section in a parturient with Still’s disease. Eur J Anaesth 2000; 17: 211-4