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Labor analgesia using dural puncture epidural in a parturient with spinal cord injury: a case report.
Abstract Number: T2D-1
Abstract Type: Case Report/Case Series
Young women with spinal cord injuries (SCI) have higher rates of successful pregnancy because of the advances in modern medicine and rehabilitation. Caring for those patients when in labor is challenging for obstetric anesthesiologists because of the risk of autonomic hyperreflexia. 1 Providing early analgesia is crucial to avoid such a complication. Dural puncture epidural (DPE) has shown a better quality of analgesia than epidural analgesia in women requesting early labor analgesia.2 In this case report, we present the anesthetic management of a parturient with SCI in labor.
A 30 year old pregnant woman at 33 weeks gestation was seen at the pre-admit clinic for assessment of her coming labor and delivery. She had a motor vehicle collision (MVC) in August 2012, resulting in tetraparesis secondary to cervical spine injury (C0-C3). The current pregnancy had progressed well. Physical examination had shown impaired gag reflex with a weak cough. There was restriction in the neck movement with Mallampati score of III. Neurological exam showed, spasticity in the upper limbs and a power rating 3/5 with difficulty initiating movement. While in the lower limbs, power was 3/5. Weakness was more pronounced on the right side in both upper and lower limbs. Sensation was grossly intact but delayed. Reflexes were brisk. MRI head and neck had showed two levels of tracheal narrowing at location of previous tracheostomy.
After discussing the case with the treating obstetrician, the decision was made to induce the patient at term (39 Weeks gestation) and to provide early labor analgesia with close monitoring to avoid autonomic hyperreflexia.
To provide a better quality of labor analgesia, DPE was chosen by the anesthesia team. At the time of DPE, patient was dilated at 5 cm and she started to get mild contractions. Loss of resistance achieved with saline. Once the epidural space was detected, 25 G spinal needle was used to make the dural puncture. After the epidural catheter was fixed, the patient received a bolus of 10 ml 0.125% Bupivacaine plus 100 mcg fentanyl. Approximately after 10 minutes, an adequate sensory blockade was achieved up to T4 with limited motor effect. The patient blood pressure was continuously measured using an arterial line. Delivery had progressed uneventfully with no signs of autonomic hyperreflexia. The patient was monitored closely for 3 days post delivery and was discharged home safely.
Dural puncture epidural analgesia offers a safe and effective early analgesia for parturients with spinal cord injuries.
1. PM Rao. Et al. Cureus. 2017 Jul 25;9(7):e1513
2. A. Chau. Et al. anasth and analg. Feb 2017. 24(2) 560-569.