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Arnold Chiari Malformation (ACM) Type I and Syringomyelia (S) in Pregnancy: Challenging Conventional Obstetric and Anesthetic Management
Abstract Number: T1I-482
Abstract Type: Original Research
Intro: Arnold Chiari malformation Type 1(ACM), is rare (2–5/10K) and is characterized by downward herniation of the cerebellar tonsils through the foramen magnum. Syringomyelia (S) present in up to 80% of ACM cases. Because Valsalva or neuraxial anesthesia (NA) can alter ICP, OB and anesthetic management of parturient with ACM & syringomyelia (ACMS) has traditionally meant cesarean delivery (CD) with GA despite lack of evidence. While case series on S have challenged conventional management, no series has focused specifically on ACMS. A G2P1 patient with ACMS presented for our preop consultation prior to repeat CD. She underwent ACM repairs as a teen and continues to experience daily HA and paresthesias. Even though she is active in competitive crossfit, her neurosurgeon recommended CD and no NA, so her 1st delivery was via CD/GA. Her upcoming CD prompted our literature review and analysis for evidence based management.
Methods: We conducted a database search using PubMed (1.19.19). Keywords used: “pregnancy” and “ACM, syringomyelia.” Inclusion criteria: pregnancies with ACMS, delivery mode and anesthetic. Exclusion criteria: full text unavailable. Descriptive statistics were performed.
Results: Our review identified 14 abstracts that met inclusion criteria. We collected data on 19 patients(21 pregnancies). Mean patient demographics: age 30.9, gravida 1.8, parity 0.45, 38 wk GA at delivery. ACMS repair data was available for 17/21. 10/17(59%) had repair, 7/17(41%) had not. For those without repair: 3/7(43%)CS, 4/7 (57%)VD. Of those CS: 1/3(33%)GA, 2/3 (67%)NA. Of those VD: 3/4(75%) had NA, 1/4(25%) PO/IV meds. For those with repair: 6/10(60%)CS, 4/10(40%)VD. Of those CS: 4/6(67%)GA, 2/6(33%)NA. Of those VD: 2/4(50%)NA, 1/4(25%)IV/PO med, 1/4(25%) nothing. No serious complications occurred in any case.
Conclusion: Our results suggest that, contrary to traditional thought, VD and NA can be considered for ACMS patients. NA may even be a safer for some. GA in ACMS patients has been associated with increased risk, such as difficult intubation given more common c-spine immobility, prolonged neuromuscular block and abnormal autonomic response on intubation/emergence with associated elevation of ICP. While we would consider NA for our patient, her case highlights the importance of patient-team decision-making to safety incorporate her wish. Final unfolding story of her CD in Feb will be presented at SOAP.
Ref- Ghaly. SNI. 2017; Garvey. AA. 2017; Kaplan CNN 2008