Background: Cesarean delivery in the United States has reached an all-time high with nearly 32% of all deliveries that take place.(1) In contrast to most other intraperitoneal procedures, neuraxial anesthesia rather than general anesthesia is considered more ideal.(2) Physiologic changes of pregnancy may increase the risk of failed airway securement and aspiration with general anesthesia, while neuraxial anesthesia offers immediate mother-neonate bonding, decreased blood loss, and improved post-operative pain control.(3, 4) In parturients with known abnormal lumbosacral neuroanatomy, however, administering neuraxial anesthesia may pose unique challenges for anesthesiologists, and potentially, risks for patients.
Case Description. A 29-year-old G1P0 female with a history significant for sacrococcygeal teratoma repaired as an infant, along with an extensive abdominal surgical history, was admitted at 34-weeks-gestation with hydronephrosis following percutaneous nephrostomy tube placement. Anesthesia was consulted to discuss the possibility of regional anesthesia for labor. Given her history of lumbosacral spine surgery, the patient was advised to undergo imaging to assess for abnormal neuroanatomy and evaluation by neurosurgery to assure minimal risk of a neuraxial procedure. Unfortunately, the patient declined this recommendation. Alternative anesthetic options for labor were discussed including: nitrous oxide analgesia, intravenous narcotics, and if required, general anesthesia. The patient was discharged following improvement of her condition.
The patient presented again at 37-weeks-gestation in labor. Her labor progressed, and after two hours of pushing, the decision was made to proceed with vacuum assisted vaginal delivery. After three unsuccessful attempts, fetal heart rate monitoring began to demonstrate significant fetal distress, so the patient was taken emergently for Cesarean section.
Once in the operating room, the patient was moved to the table, standard monitors were applied, and general anesthesia was induced by rapid sequence. The patient was easily intubated using video laryngoscopy without complications. Surgical incision immediately followed airway securement, and entry to the peritoneum demonstrated evidence of dense adhesion formation between the small bowel and both the uterus and retroperitoneum. The neonate was delivered shortly thereafter without issue. The abdominal entry was complicated by small bowel serosal injuries prompting intraoperative emergent general surgery consult and post-partum hemorrhage of two liters requiring transfusion of packed red blood cells and fresh frozen plasma. Following completion of the surgery, the patient was extubated without issue and transferred to the PACU in stable condition.
Discussion. Management of labor analgesia in patients with known abnormal lumbosacral neuroanatomy is not a well-defined topic within anesthesia practice. Neuraxial anesthesia in these patients may be technically challenging because of their abnormal anatomy, increasing the risk of failed attempts, vascular trauma, and even permanent neurological injury (5). Antepartum assessment with spinal imaging and neurosurgical consultation may provide valuable information that will allow minimization of injury and maximally successful analgesia. It is paramount that all anesthesia options for delivery are discussed, including general anesthesia, as was required in this case. If rapid cesarean delivery is required, potential risks associated with surgical entry and general anesthesia need to be anticipated with a goal of improving outcomes for the patient.
