///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Anesthetic Management for a Parturient with Splitting of the Spinal Cord—Diastematomyelia

Abstract Number: RF5BH-98
Abstract Type: Case Report Case Series

Stephanie K Woodward MD1 ; Stephen Acosta MD2; Lacey E Straube MD3; Willaim H Goodnight MD4; Gina Silverstein MD5; David C Mayer MD6

Background: Diastematomyelia is a rare congenital disorder characterized by longitudinal splitting of the spinal cord. Parturients with diastematomyelia are poor candidates for neuraxial anesthesia due to unusual vertebral/spinal cord anatomy, propensity for tethered cord, and prior surgical management. To our knowledge management of parturients with diastematomyelia has not been previously described.

Case: A 33-year-old 4’ 9” G2P0010 at 37w0d with diastematomyelia was admitted for primary cesarean delivery (CD) for breech presentation and gestational hypertension. Her history was notable for back pain, bicornuate and bicollis uterus, and idiopathic tachycardia (baseline 110-120 BPM). She was status-post multiple vertebral operations including tethered cord repair, resulting in a shortened thorax. Her neurological exam prior to pregnancy was normal apart from bilateral hand/right foot numbness and bilateral leg weakness with prolonged supine positioning. She had a Mallampati 1 airway and no history of airway complications.

The patient was positioned awake on the operating table using blankets with patient feedback. She was uneventfully intubated with direct laryngoscopy after rapid sequence induction. Tachycardia slightly above baseline (130-150 BPM) persisted intraoperatively. Delivery was uncomplicated. A bicornuate uterus was confirmed. Mild uterine atony resolved with oxytocin and one dose of methylergonovine. Estimated blood loss was 800mL.

The patient was extubated uneventfully. Post-operative pain control was suboptimal despite 400mg fentanyl, 1mg hydromorphone, and 8mg morphine. Ultrasound-guided bilateral transversus abdominal plane (TAP) blocks were placed with 60mL 0.25% bupivacaine. Although placement was somewhat challenging given her short thorax, this provided 12 hours of pain control. Pain was then controlled using acetaminophen, NSAIDs, and oxycodone.

Postoperative telemetry showed sinus tachycardia intermittently up to 180 BPM. She was treated with pain control and esmolol. Bleeding was negligible, electrolyte and thyroid function were normal, and cardiology consult recommended no further workup. Her heart rate returned to baseline prior to discharge on post-operative day 4.

Discussion: Parturients with diastematomyelia require special consideration for the anesthesia and obstetric providers. CD may be more common in this population due to cephalopelvic disproportion with significant spinal malformations. This patient would not have tolerated prolonged lithotomy positioning. She was not a candidate for neuraxial anesthesia given her anatomy and prior surgical interventions; TAP blocks and multimodal analgesia were very beneficial. In patients who are candidates for trial of vaginal delivery, nitrous oxide or IV remifentanil may be adjuncts for labor analgesia.

CJ Murphy, E Stanley, E Kavanagh, PE Lenane, CL McCaul. Int J Obstet Anesth. 2015

SOAP 2019