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Between a Rock and a Hard Place: Labor Analgesia in a Patient with Congenital Pulmonic Stenosis and a new onset intracranial lesion.
Abstract Number: RF1BA-341
Abstract Type: Case Report Case Series
Epidural anesthesia is often utilized in patients with heart disease, pulmonary hypertension or severe pre-eclampsia. Its benefits include a decrease in maternal catecholamine release thus reducing the stress on the maternal cardiorespiratory system. An often-cited contraindication to neuraxial anesthesia is the presence of an intracranial tumor. Patients with intracranial tumors are assumed to have an increase in intracranial pressure (ICP) and inadvertent dural puncture during epidural placement can have catastrophic consequences.
21 yo F G2P0 who presented at 37 weeks for induction of labor for gestational hypertension with a PMH of HFpEF, congenital pulmonic stenosis s/p balloon valvuloplasty, anomalous right coronary artery s/p unroofing procedure, kyphoscoliosis s/p T3-T12 fusion, asthma, Wilm’s tumor s/p right nephrectomy and new onset seizures from a lesion of the medial left parasagittal parietal lobe. Her most recent TTE was significant for an EF estimated at 50-55%, abnormal septal motion and moderate pulmonary regurgitation. A MRI showed a T2 FLAIR hyperintense lesion with mild mass effect without midline shift. A multidisciplinary team was consulted to evaluate options for labor analgesia. Based on the absence of evident brain herniation or midline shift and patent basal cisterns the patient was deemed suitable for epidural catheter placement. An epidural block was performed by a senior anesthesiologist at the L4-5 interspace using a 17G Tuohy needle. Epidural analgesia was achieved with careful titration of PCEA. The patient tolerated the procedure well with no untoward events. The patient had a spontaneous vaginal delivery without complications.
Intracranial lesions are cited as contraindications to neuraxial anesthesia due to the possibility of inadvertent dural puncture and subsequent brain herniation through the foramen magnum. However, a benefit of neuraxial anesthesia is the reduction of maternal catecholamine release during labor thus reducing the strain on the heart. Due to the history of HFpEF in our patient, we preferred to utilize an epidural block for labor analgesia. Given the concomitant presence of a brain lesion, it was necessary to seek expert opinion by neurosurgery with regards to the safety of epidural placement. After a review of the imaging and a neurological examination it was determined the patient likely did not have an increase in ICP thus making her a candidate for epidural placement. Careful titration of the epidural and avoidance of hypotension were paramount to reduce the stress response and associated catecholamine release.
An epidural block for labor analgesia may be a suitable option for labor analgesia in a patient with cardiac dysfunction and an intracranial lesion. A thorough review of the patient’s imaging, history and clinical exam and consultation with a multidisciplinary team should guide decision making.