Epidural anaesthesia and neural tube defects

A Case Report of Fluoroscopically Guided Epidural Catheter Placement in a Parturient with History of Tethered Cord, Super-Morbid Obesity, and Risk for Difficult Airway

Tethered cord syndrome results from adherence of the conus medullaris to the sacrum and may be associated with high complication rates from neuraxial anesthesia. We present the case of a 32-year-old gravida 2 para 0 patient with a history of lipomyelomeningocele (one of several types of spina bifida) and tethered cord status post repair, residual low-lying conus medullaris, supermorbid obesity (body mass index of 58), and Mallampati IV airway, who underwent successful fluoroscopically guided epidural catheter placement for vaginal delivery. Risks and benefits of epidural catheter utilization and methods of placement are reviewed.

Women's health guidelines for the care of people with spina bifida

Women and girls with spina bifida have specific health care concerns. It is essential that they, and their health care providers have access to information to help them make healthy choices throughout their lifespan. This article aims to address key aspects of health pertinent to girls and women with spina bifida and outlines the SB Women's Health Guidelines for the Care of People with Spina Bifida. Further research into this area is needed.

Guideline No. 416: Labour, Delivery, and Postpartum Care for People with Physical Disabilities

OBJECTIVE

To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada.

TARGET POPULATION

This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline.

OUTCOMES

Safe and compassionate care for people with physical disabilities who are giving birth.

BENEFITS, HARMS, AND COSTS

Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth.

EVIDENCE

A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

RECOMMENDATIONS

Pragmatic approach to neuraxial anesthesia in obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system

Neuraxial anesthesia provides optimal labor analgesia and cesarean delivery anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential concerns include mechanical interference, patient injury and the need for imaging. Unfortunately, the existing literature regarding neuraxial anesthesia in these patients is largely limited to case series and rare retrospective studies. The lack of practice guidance may lead to unwarranted fear of patient harm and subsequent avoidance of neuraxial anesthesia for cesarean delivery or neuraxial analgesia for labor, with additional risks of exposure to general anesthesia. In this narrative review, we use available evidence to recommend a framework when considering neuraxial anesthesia for an obstetrical patient with neuraxial pathology.

Spina bifida in pregnancy: A review of the evidence for preconception, antenatal, intrapartum and postpartum care

Women with spina bifida in pregnancy require complex multi-disciplinary management. Most women have uncomplicated pregnancies; however, complications are more frequent than in 'low risk' pregnancies. Careful antenatal planning and management of the complications can optimise outcome. There are currently no guidelines on the management of pregnant women with spina bifida, but there is a growing body of evidence from case reports and series examining the antenatal and postnatal course of these women. In this review, we examine the available literature and provide a framework on the prenatal counselling, antenatal, intrapartum and postnatal management of pregnant women with spina bifida.

Epidural Analgesia for Labour in a Patient with a Neural Tube Defect

This report describes the use of epidural analgesia in a patient with a known neural tube defect. The patient had a severe form of spina bifida cystica which had been operated on in childhood. She had a neurogenic bladder but otherwise had preserved neurological function. She had an epidural catheter inserted in early labour, providing effective analgesia for an uneventful birth. This case outlines the severity of the cystica category of neural tube defects, the added anatomical challenges of previous surgery and the difficulties that may arise from the utilization of epidural analgesia. The case demonstrates that epidural analgesia can be utilized despite such a disorder. A thorough history and examination are essential, as are the patient's informed consent and knowledge of possible complications.

[Pregnancy and delivery for women with congenital spinal cord defects and neurogenic bladder]

INTRODUCTION

Data are scarce regarding pregnancy and delivery among women with a neurogenic bladder due to congenital spinal cord defects.

OBJECTIVE

To report the obstetrical and urological outcomes of women with congenital spinal cord defects and vesico-sphincteric disorders.

METHODS

A retrospective multicentric study included all consecutive women with a neurogenic bladder due to congenital spinal defects, who delivered between January 2005 and December 2014. The following data were collected: demographics, neuro-urological disease characteristics, urological and obstetrical history, complications during pregnancy, neonatal outcomes, and changes in urological symptoms.

RESULTS

Overall, sixteen women, median age 29,4 years old (IQR 22-36), had a total of 20 pregnancies and 21 births (15 caesareans, 5 vaginal deliveries). Prior to the beginning of their first pregnancy, 12 patients were under intermittent self-catheterization. Symptomatic urinary tract infections during pregnancy occurred in 11 pregnancies, including 4 pyelonephritis. In 4 women, stress urinary incontinence had worsened but recovered post-partum. In 3 women, de novo clean intermittent catheterization became necessary and had to be continued post-partum. During 3 pregnancies, anticholinergic treatment had been started or increased because of urge urinary incontinence worsened. These changes were maintained after delivery. The median gestational age at birth was 39.0 weeks (IQR 37.8-39.5). There were 15 caesarean sections, of which 9 were indicated to prevent a potential aggravation of vesico-sphincteric disorders. Among the 5 pregnancies with vaginal delivery, there was no post-partum alteration of the sphincter function.

CONCLUSION

Successful pregnancy outcome is possible in women with congenital spinal cord defects and vesico-sphincteric disorders but it requires managing an increased risk of urinary tract infections, caesarean section, and occasionally worsened urinary incontinence.

LEVEL OF EVIDENCE

5.

Occult Spinal Dysraphism in Obstetrics: A Case Report of Caesarean Section with Subarachnoid Anaesthesia after Remifentanil Intravenous Analgesia for Labour

Neuraxial techniques of anaesthesia and analgesia are the current choice in obstetrics for efficacy and general low risk of major complications. Concern exists about neuraxial anaesthesia in patients with occult neural tube defects, regarding both labour analgesia and anaesthesia for Caesarean section. Recently, remifentanil infusion has been proposed as an analgesic technique alternative to lumbar epidural, especially when epidural analgesia appears to be contraindicated. Here, we discuss the case of a pregnant woman attending at our institution with occult, symptomatic spinal dysraphism who requested labour analgesia. She was selected for remifentanil intravenous infusion for labour pain and then underwent urgent operative delivery with spinal anaesthesia with no complications.

The preoperative assessment of obstetric patients

The importance of early identification and management of the high-risk obstetric patient is emphasised in the Confidential Enquiry into Maternal and Child Health (CEMACH) report. High-risk patients who need anaesthetic input include those with airway problems, cardiorespiratory disease and rare genetic conditions, such as malignant hyperthermia and suxamethonium apnoea. Anaesthetic options for labour analgesia as well as anaesthesia for operative delivery will need to be discussed in detail with the patient if a delivery management plan is to be constructed. Input from other medical teams, such as cardiologists or haematologists, are often needed. Ultimately, these measures should reduce maternal morbidity and mortality.

UK registry of high-risk obstetric anaesthesia: report on neurological disease

The UK registry of high-risk obstetric anaesthesia was set up in 1996 to collect reports of high-risk pregnancy, pool them into a central database and make them available to obstetric anaesthetists. This paper summarises the data relating to 102 patients with neurological disease who were reported to the registry between 1997 and 2002. The two most common conditions reported were spina bifida and multiple sclerosis. We describe the features and management of these and other cases.

Labor analgesia for pregnant women with spina bifida: What does an obstetrician need to know?

Neural tube defects, with a birth incidence of approximately 1/1,000, are the second most common (after congenital heart defects) type of congenital birth defects. The most common clinical presentations of neural tube defects include spina bifida and anencephaly. Spina bifida, which is one of the most common, serious malformations of human structure, is a general term that encompasses a wide range of malformations. With constant improvements in medical and surgical care, and subsequent decreases in spina bifida-related mortality and morbidity many women with these defects are reaching childbearing age. Provision of labor analgesia in pregnant women with spina bifida continues to be a challenge. This manuscript attempts to provide a synopsis of the available literature on labor analgesia in pregnant women with spina bifida.

Caesarean section using a combined spinal epidural technique in a patient with arthrogryposis multiplex congenita

A case of a woman with arthrogryposis multiplex congenita presenting for elective caesarean section is reported. A combined spinal epidural anaesthetic technique was used. Aetiology and anaesthetic considerations for patients with arthrogryposis multiplex congenita are discussed. The importance of early referral to the anaesthetic team of patients with intercurrent disease or congenital syndromes is emphasised.

Failed intubation in a parturient with spina bifida

We describe a case of unexpected difficult intubation and ventilation during induction of general anaesthesia for caesarean section. This case was particularly challenging as the parturient suffered with particularly severe cord tethering following surgery for spina bifida as a child. The observed change in anticipated intubation difficulty during pregnancy, and the use of the laryngeal mask airway as a life-saving device in obstetrics are described. Consideration of the difficulties of anaesthetising the patient with spina bifida for caesarean section in general, and the issues relevant in deciding whether to continue with surgery or to wake the patient up in particular are discussed. Suggestions are made for the management of this emergency situation in those not skilled in fibreoptic intubation.