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Anesthetic Management of a Parturient with Advanced Amyotrophic Lateral Sclerosis Undergoing Dilation and Curettage: A Case Report and Review of the Literature
Abstract Number: RF5AH-102
Abstract Type: Case Report Case Series
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that results in > 50% of patients passing away within 3 years of symptom onset. Anesthesia presents a unique challenge, as these patients are susceptible to multiple adverse outcomes. The physiologic changes associated with pregnancy can further increase this risk. Here, we discuss the management of a pregnant woman with ALS presenting for dilatation and curettage (D&C) for an incidental pregnancy.
Our patient is a 38-year-old G6P4014 female who presented with abdominal and flank pain. Her history was significant for advanced ALS and recurrent urinary tract infections. She was quadriplegic, and also required the use of BiPAP. Workup confirmed a diagnosis of pyelonephritis and also revealed a 13 week incidental pregnancy. A multidisciplinary team recommended termination of the pregnancy given the substantial risk of exacerbating her already debilitating ALS symptoms. For the case, we opted for para-cervical local anesthesia (30 mL of lidocaine 1%) supplemented with low doses of midazolam and dexmedetomidine. This decision was taken due to our concern for aspiration and post-operative respiratory decompensation with general anesthesia given the patient’s bulbar symptoms. The procedure was without incident, and the patient maintained her pre-operative level of comfort and stable vital signs throughout. She had an uneventful post-operative course and was discharged home the next day.
Descriptions of ALS in pregnancy are rare, not least because it primarily affects middle-aged males. While neonatal outcomes are generally positive, the same cannot be said of the parturient herself, as patients with advanced ALS have experienced clinical deterioration from the increased ventilatory requirements of pregnancy. While the successful application of both general and neuraxial anesthesia has been reported, there are known risks to both. Post-operative respiratory depression and aspiration remain the chief concerns surrounding general anesthesia, with neurologic injury often precluding neuraxial. In the case of our patient, we have demonstrated a method in which both general and neuraxial anesthetic risks could be avoided. As evidence in favor of any specific anesthetic technique in this population is lacking, continued reliance on multidisciplinary panels is likely the best system for preventing deleterious patient outcomes.
Prabhakar A, Owen CP, Kaye AD. Anesthetic management of the patient with amyotrophic lateral sclerosis. Journal of anesthesia. 2013 Dec;27(6):909-18.
Leveck DE, Davies GA. Rapid progression of amyotrophic lateral sclerosis presenting during pregnancy: a case report. Journal of Obstetrics and Gynaecology Canada. 2005 Apr;27(4):360-2.
Kopp SL, Jacob AK, Hebl JR. Regional Anesthesia in Patients With Preexisting Neurologic Disease. Regional anesthesia and pain medicine. 2015 Sep-Oct;40(5):467-78.