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Neuraxial Anesthesia for Caesarean Section in a Patient with Anti-NMDA-Receptor Encephalitis
Abstract Number: RF1BA-322
Abstract Type: Case Report Case Series
Anti-N-methyl-D-aspartate encephalitis (anti-NMDARE) is an autoimmune disorder that predominately affects females (1). Common clinical manifestations include psychotic symptoms, neurologic symptoms, and autonomic instability (2). One of the only case reports of neuraxial anesthesia for an anti-NMDARE patient documents failure of spinal block but success after epidural dosing. The following case may help provide insight when considering neuraxial anesthesia for anti-NMDARE patients (3).
A 20-year-old G1 female at 10 weeks and 6 days presented with new onset refractory status epilepticus, necessitating intubation for airway protection and prolonged ICU care. A diagnosis of anti-NMDARE was made based on detection of NMDA antibodies. She received multiple immunomodulary treatments (steroids, PLEX, IVIG, cyclophosphamide and rituxan). She subsequently suffered respiratory failure, underwent a tracheostomy and eventually decannulated. She was discharged after five months and continued to follow with neurology and MFM. A scheduled induction was planned for 39 weeks and 2 days but rescheduled when she was readmitted at 38 weeks and 4 days for a general tonic clonic seizure. During this admission, she continued to have breakthrough seizures, tachycardia secondary to autonomic dysfunction, impaired mobility from contractures, torticollis, limited spinal flexion, and anxiety/PTSD.
Based on the position of the fetus (transverse lie), the obstetric service scheduled a caesarean section for 38 weeks and 6 days. She was pre-treated with sodium citrate 30 ml PO, famotidine 20 mg IV, and ondansetron 8 mg IV. A combined spinal epidural was successfully placed via midline approach. Intrathecal injection was performed utilizing 1.3 mL of 0.75% hyperbaric bupivacaine, 20 mcg of fentanyl, and 150 mcg of preservative free morphine. A bilateral T6 surgical block was obtained and surgery commenced. A phenylephrine drip was started after incision and titrated to achieve desirable blood pressures. A healthy male was delivered 7 minutes after incision and oxytocin was given after placental delivery. An epidural test dose of 3 mL of 1.5% lidocaine with 1:200,000 epinephrine was given at approximately one hour after spinal injection. Additionally, 10 mL of 3% chloroprocaine and 80 mcg of fentanyl were injected into the epidural space. Acetaminophen and ketorolac were administered for additional post-operative analgesia. Estimated blood loss was 1000 ml. Post-op course was uncomplicated and she was discharged home on POD#4.
Our case shows that neuraxial anesthesia can be a safe and effective form of anesthesia for parturients with anti-NMDARE. While anti-NMDARE is rare during pregnancy, it is commonly associated with ovarian teratomas, which often necessitate resection (4).
1. J Anesth. 2017; 31:282-285.
2. J Obstet Gynaecol Res. 2017 April; 43(4):768-774.
3. International Journal of Obstetric Anesthesia. 2017; 31: 104-107.
4. Rev Bras Anestesiol. 2017;67(6):647-650.