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Delgado García DR, Latorre Andreu P, Fernández Tomás B, Tébar Cuesta MI. Marfan syndrome in a term-pregnant woman with aortic root dilatation between 40 and 45 mm. ACTA ACUST UNITED AC 2018; 66:49-52. [PMID: 30447896 DOI: 10.1016/j.redar.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/30/2018] [Accepted: 08/31/2018] [Indexed: 10/27/2022]
Abstract
Marfan syndrome is a hereditary connective tissue disorder. The main cause of mortality in these patients is due to cardiovascular complications related to dilation of an aneurysm and dissection of the aortic root, a situation that increases their risk due to the physiological changes that occur during pregnancy, childbirth and puerperium. The case is presented of a pregnant woman with Marfan syndrome and aortic root dilatation of 42mm. The issues are discussed, such as the mode of delivery (vaginal delivery vs. caesarean section) depending on the aortic root diameter or the choice of type of anaesthesia (general vs. neuraxial) in these cases.
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Affiliation(s)
- D R Delgado García
- Servicio de Anestesiología y Reanimación, Hospital 12 de Octubre, Madrid, España.
| | - P Latorre Andreu
- Servicio de Anestesiología y Reanimación, Hospital 12 de Octubre, Madrid, España
| | - B Fernández Tomás
- Servicio de Anestesiología y Reanimación, Hospital 12 de Octubre, Madrid, España
| | - M I Tébar Cuesta
- Servicio de Anestesiología y Reanimación, Hospital 12 de Octubre, Madrid, España
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2
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Vacula BB, Gray C, Hofkamp MP, Noonan PT, McAllister RK, Pilkinton KA, Diao Z. Epidural analgesia complicated by dural ectasia in the Marfan syndrome. Proc (Bayl Univ Med Cent) 2017; 29:385-386. [PMID: 27695168 DOI: 10.1080/08998280.2016.11929477] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Patients with the Marfan syndrome are considered to be high risk during pregnancy and warrant a complete multidisciplinary evaluation. One goal is to minimize hemodynamic fluctuations during labor since hypertensive episodes may result in aortic dissection or rupture. Although they may prevent these complications, neuraxial techniques may be complicated by dural ectasia. The case of a parturient with the Marfan syndrome and mild dural ectasia is presented. During attempted labor epidural placement, unintentional dural puncture occurred. A spinal catheter was used for adequate labor analgesia, and a resultant postdural puncture headache was alleviated by an epidural blood patch under fluoroscopic guidance.
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Affiliation(s)
- Benjamin B Vacula
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
| | - Chelsea Gray
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
| | - Michael P Hofkamp
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
| | - Patrick T Noonan
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
| | - Russell K McAllister
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
| | - Kimberly A Pilkinton
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
| | - Zhiying Diao
- Department of Anesthesiology, Texas A&M University Health Science Center College of Medicine and Scott & White Memorial Hospital
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3
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Epidural Anesthesia for Cesarean Section in a Pregnant Woman with Marfan Syndrome and Dural Ectasia. Case Rep Obstet Gynecol 2017; 2017:2126310. [PMID: 28611929 PMCID: PMC5458362 DOI: 10.1155/2017/2126310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 04/19/2017] [Indexed: 11/29/2022] Open
Abstract
Marfan syndrome (MFS) is a genetic disorder of connective tissue, characterized by variable clinical features and multisystem complications. The anesthetic management during delivery is debated. Regional anesthesia has been used with success during cesarean delivery, but in some MFS patients there is a probability of erratic and inadequate spread of intrathecal local anesthetics as a result of dural ectasia. In these cases, epidural anesthesia may be a particularly useful technique during cesarean delivery because it allows an adequate spread and action of local anesthetic with a controlled onset of anesthesia, analgesia, and sympathetic block and a low risk of perioperative complications. We report the perioperative management of a patient with MFS and dural ectasia who successfully underwent cesarean section using epidural technique anesthesia. The previous pregnancy of this woman ended with cesarean section with a failed spinal anesthesia that was converted to general anesthesia due to unknown dural ectasia at that time.
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Cronin J, Cuschieri HB, Dong X, Oswald G, Russo M, Dietz H, Murphy J. Anesthesia Considerations for Cesarean Delivery in a Patient with Loeys-Dietz Syndrome. ACTA ACUST UNITED AC 2015; 4:47-8. [DOI: 10.1213/xaa.0000000000000114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Dural ectasia is one of the likely causes of incomplete or failed spinal anaesthesia. Its association with diseases like Marfans syndrome, neurofibromatosis, osteogenesis imperfecta, vertebral fracture, postopertative adhesions, trauma etc., is often overlooked as a reason for inadequate spinal anaesthesia. Greater than normal volume of cerebrospinal fluid in the lumber theca in dural ectasia is postulated to restrict the spread of intrathecally injected Local anaesthetic. Here, we report a case of failed spinal anaesthesia but successful epidural anaesthesia in later setting in a patient with dural ectasia.
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Affiliation(s)
- Neha Gupta
- Department of Anaesthesia, M. L. B. Medical College, Jhansi, Uttar Pradesh, India
| | - Veena Gupta
- Department of Anaesthesia, M. L. B. Medical College, Jhansi, Uttar Pradesh, India
| | - Abhishake Kumar
- Department of Anaesthesia, M. L. B. Medical College, Jhansi, Uttar Pradesh, India
| | - Gaurav Kumar
- Department of Orthopaedics, Jhansi Orthopaedic Hospital, Jhansi, Uttar Pradesh, India
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McNeilly G, Nicholl A, Broadway J, Rao S. Dural ectasia in Marfan's syndrome: magnetic resonance imaging appearances and anaesthetic experience of three deliveries. Int J Obstet Anesth 2013; 22:337-9. [PMID: 23968648 DOI: 10.1016/j.ijoa.2013.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 05/27/2013] [Accepted: 06/03/2013] [Indexed: 11/29/2022]
Abstract
Neuraxial anaesthetic techniques are considered useful to minimise haemodynamic stress during labour. In Marfan's syndrome, connective tissue abnormalities not only affect the thoracic aorta but also predispose to dural ectasia. A dural ectatic sac may cause difficulties with neuraxial analgesia and anaesthesia. We discuss magnetic resonance imaging appearances and anaesthetic experience of three deliveries in a parturient with stable echocardiographic findings. We consider that epidural analgesia and anaesthesia are a safe and pragmatic solution for labour and delivery. Lumbo-sacral magnetic resonance imaging at presentation will define dural ectasia and assist in management.
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Affiliation(s)
- G McNeilly
- Department of Anaesthetics, Ipswich Hospital NHS Trust, Heath Road, Ipswich, UK
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Allyn J, Guglielminotti J, Omnes S, Guezouli L, Egan M, Jondeau G, Longrois D, Montravers P. Marfan’s Syndrome During Pregnancy. Anesth Analg 2013; 116:392-8. [DOI: 10.1213/ane.0b013e3182768f78] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Baghirzada L, Krings T, Carvalho JCA. Regional anesthesia in Marfan syndrome, not all dural ectasias are the same: a report of two cases. Can J Anaesth 2012; 59:1052-7. [PMID: 22976428 DOI: 10.1007/s12630-012-9778-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 08/21/2012] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND The anesthetic management of women with Marfan syndrome and dural ectasia undergoing Cesarean delivery remains controversial. We present two cases of patients with Marfan syndrome and dural ectasia where neuraxial anesthesia was used successfully. CASE 1: A 31-yr-old G1P0 female with Marfan syndrome presented for elective Cesarean delivery at 35(3/7) weeks' gestation. The magnetic resonance imaging of her spine revealed significant dural ectasia in the lumbosacral area with a mean lumbar dural sac area of 4.71 cm(2). Intrathecal administration of 0.75% hyperbaric bupivacaine 9 mg produced only limited perineal analgesia. The epidural catheter was titrated, and 0.5% bupivacaine 150 mg were required to achieve a T4 sensory level. CASE 2: A 34-yr-old G1P0 female with Marfan syndrome presented for elective Cesarean delivery at 37 weeks' gestation. The intrathecal administration of 0.75% hyperbaric bupivacaine 13.5 mg produced a T5 sensory level. Magnetic resonance imaging of her spine prior to discharge confirmed the diagnosis of moderate dural ectasia with a mean lumbar dural sac area of 3.61 cm(2). DISCUSSION The two patients described in this report responded differently to spinal anesthesia, most likely based on the severity of their dural ectasia. Although preoperative magnetic resonance imaging may help to identify patients at risk for a failed spinal, we suggest considering a combined spinal-epidural technique in cases of dural ectasia.
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Affiliation(s)
- Leyla Baghirzada
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.
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Abstract
Advances in the surgical palliation and correction of congenital heart lesions have improved survival and increased the number of patients living into adulthood. Although pregnancy outcomes will be favorable for most patients with congenital heart disease, the cardiovascular challenges associated with pregnancy and delivery are best managed with a multidisciplinary approach during the puerperium. This review addresses the prevalence, physiology, risk assessment, peripartum complications, and anesthetic management of the pregnant patient with underlying congenital heart disease.
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Affiliation(s)
- Amy J Ortman
- University of Kansas Medical Center, Kansas City, KS 66160-7415, USA.
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Kim G, Ko JS, Choi DH. Epidural anesthesia for cesarean section in a patient with Marfan syndrome and dural ectasia -A case report-. Korean J Anesthesiol 2011; 60:214-6. [PMID: 21490825 PMCID: PMC3071487 DOI: 10.4097/kjae.2011.60.3.214] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 10/05/2010] [Accepted: 10/07/2010] [Indexed: 11/29/2022] Open
Abstract
Pregnancy is considered a period of high risk for cardiovascular complications in patients with Marfan syndrome. Therefore the choice of anesthetic technique for delivery should be focused on minimizing hemodynamic fluctuations, and preferably provide adequate post-operative pain control. For this purpose, neuraxial blocks, such as spinal or epidural anesthesia, may be deemed a safe option. However, dural ectasia is present in 63-92% of patients with Marfan syndrome, and the increased amount of cerebrospinal fluid volume is thought to be one of main reasons for spinal anesthesia failure. We report herein the peri-operative management of a patient with Marfan syndrome and dural ectasia for cesarean section using epidural anesthesia.
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Affiliation(s)
- Gahyun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
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Goldszmidt E, Macarthur A, Silversides C, Colman J, Sermer M, Siu S. Anesthetic management of a consecutive cohort of women with heart disease for labor and delivery. Int J Obstet Anesth 2010; 19:266-72. [DOI: 10.1016/j.ijoa.2009.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 05/22/2009] [Accepted: 09/22/2009] [Indexed: 10/19/2022]
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