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Neuraxial labor analgesia in a parturient with Lyme disease
Abstract Number: RF3AC-360
Abstract Type: Case Report Case Series
Introduction: Lyme Disease (LD), a zoonosis caused by Borrelia burgdorferi, is the most common tick-borne infection in the United States (1). While studies on LD have not confirmed an association between B. burgdorferi and adverse birth outcomes (2), this multi-system disease process has clinical manifestations that impact peripartum management. Patients with LD require careful assessment of cardiac and neurologic systems, as known complications include carditis, radiculitis and meningitis (3). CNS involvement is an important consideration when deciding to perform neuraxial blocks in these patients (3). We report a rare case of LD in a parturient presenting for induction of labor.
Case report: 34-y.o. G4P0 at 36 weeks gestation presented to her primary physician with flu-like symptoms. She reported a 3-day history of fever (100.6 F), malaise and generalized myalgia, for which she was prescribed oseltamivir for presumed influenza. The patient defervesced, however two days later developed bilateral hand swelling, polyarthralgia (hands, shoulders, neck and jaw) and a diffuse erythematous targetoid rash. She reported several insect bites after recent travel to upstate New York. The patient was referred to outpatient Dermatology who prescribed cefuroxime 500mg PO BID for presumed early disseminated LD. The patient was then admitted for formal workup by the Infectious Disease (ID) service. LD was confirmed by positive IgG and IgM antibodies to B. burgdorferi. The patient was started on IV ceftriaxone for 2 days, then transitioned to cefuroxime 500mg PO BID to complete a 21-day course of antibiotics. She was discharged on hospital day 2 after a confirmed clinical response and absence of a Jarisch–Herxheimer reaction to the antibiotics. She had near complete symptom relief after 5 days of therapy.
The patient presented to L&D for induction of labor at 39.3 weeks. ID cleared the patient for neuraxial analgesia given the completed 21-day course of antibiotics and symptom resolution. She had an uncomplicated vaginal delivery under combined-spinal epidural.
Discussion: Anesthetic management of the parturient with disseminated LD can be challenging.
Cardiac involvement requires close monitoring for carditis-induced heart failure and atrioventricular blocks, as both can be fatal if unrecognized. Neuraxial blockade may be contraindicated in LD patients due to the concern for introduction of the infective agent into the CNS. The impact of neuraxial techniques on disease progression in known CNS involvement is also unclear. Given the lack of evidence of adverse outcomes related to neuraxial procedures in LD patients (3), we believe that it is safe to perform in parturients with known CNS involvement, and those who have completed antibiotic therapy and confirmed symptom resolution.
1. Shapiro ED. N Engl J Med. 2014;370(18):1724-31.
2. Waddell, LA, et. al. PLoS One. 2018;13(11):e0207067.
3. Sultan P, et al. Anaesthesia. 2012;67(2):180-3.