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Management of Emergency Cesarean Delivery in a Parturient with Acute Transverse Myelitis
Abstract Number: FC10-474
Abstract Type: Case Report Case Series
A 41-year-old female G1P0 at 15 weeks gestation presented to an outside hospital with loss of sensation in her lower extremities 11 days after a flu-like illness. The hypoesthesia progressed from numbness to paralysis. Lumbar puncture revealed marked pleocytosis, elevated protein, and was negative for common neurotropic viruses. MRI showed extensive T2 hyper-intensity extending from the cervical spine to the conus. Neurological examination revealed paraplegia with 0/5 strength in the bilateral lower extremities and impaired sensation of all modalities below T8. The patient was diagnosed with acute transverse myelitis (TM) and treated with plasmapheresis, cyclophosphamide, and steroids.
The patient presented to our labor & delivery suite at 33 weeks with vaginal bleeding and a neurologic exam that was stable since her diagnosis. A non-reassuring fetal heart tracing with recurrent prolonged variable decelerations resulted in a decision for urgent cesarean delivery. A discussion was held with the patient and her family regarding the risks and benefits of neuraxial versus general anesthesia (GA) in the setting of acute TM. Although the patient desired neuraxial to be awake for delivery, she had a reassuring airway exam, had been NPO for greater than 8hrs and there was concern for worsening neurologic disease with neuraxial. While preparing for the operating room, the fetus experienced a terminal bradycardia requiring emergent delivery under GA. After rapid sequence induction, the airway was secured and a viable infant was delivered. In the 4 months since delivery, the patient has shown a gradient of improvement in her neurologic exam with perception of pinprick intermittently down to T12 and improved tone in the lower extremities.
TM is an acute inflammatory lesion of the spinal cord which results in motor, sensory, and autonomic dysfunction. Reports of acute TM during pregnancy are extremely rare (1,2). Concerns for the TM parturient requiring anesthesia include possible autonomic dysreflexia, progressive neurologic disease, prolonged neuromuscular blockade and hyperkalemia in response to depolarizing neuromuscular blockade. Evidence suggests that neuraxial anesthesia can reduce symptoms of autonomic dysreflexia in susceptible laboring women. Epidural anesthesia has been reported with both chronic and acute TM patients without apparent complication (1) but there is ongoing controversy over the safety of neuraxial techniques in patients with preexisting neurologic disease, especially in the setting of an acute process. While GA is commonly avoided in obstetrics for concern of difficult airway and aspiration risk, our patient’s exam and NPO status were reassuring. For every surgical delivery, the risks and benefits of neuraxial anesthesia vs. GA are weighed. In this case, urgency ultimately dictated the need to proceed with GA.
1. Thomas et al. Int J Obstet Anesth. 2010;19(4):467-8.
2. Hunter et al. J of Obstet Anaesth and Crit Care. 2018;8(1):58.