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We present the anesthetic management of a 23-year-old gravida 2 para 0-0-1-0 with a history of mitral valve replacement secondary to congenital mitral dysplasia. The hemodynamic changes of pregnancy had resulted in severe functional mitral stenosis of her mechanical valve, which was significantly undersized for her current body surface area. Her complex cardiac history required our multidisciplinary team to focus on peripartum anticoagulation management, extracorporeal membrane oxygenation (ECMO) preparation under a dural puncture epidural (DPE) technique, and managing the hemodynamic changes that are critical for a congenital heart disease parturient.

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Not all postpartum headaches are caused by dural puncture, and it is possible for postpartum patients to have >1 cause for headache. After neuraxial block with an incidental large-gauge dural puncture, our patient developed a severe, classic postdural puncture headache which initially responded to an epidural blood patch. The patient was readmitted 2 days after discharge complaining of recurrent headache less characteristic of a postdural puncture headache, now being bifrontal/retro-orbital and without clear positional component. Computerized tomography and magnetic resonance imaging revealed an enlarged pituitary gland with a possible hemorrhagic focus; all endocrine parameters were normal. The patient was ultimately diagnosed with lymphocytic adenohypophysitis, an autoimmune inflammation of the anterior pituitary gland.

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PURPOSE: To describe the risk factors for epidural abscess (EA) formation following epidural analgesia in a parturient with pruritic urticarial papules and plaques of pregnancy (PUPPP). CLINICAL FEATURES: A 33 yr-old gravida 2 nulliparous patient at 36 weeks gestation presented with severe pre-eclampsia, and PUPPP (treated with prednisone). Magnesium prophylaxis was started and labour was induced. An epidural catheter was placed at the L(3-4) level using standard aseptic technique. Bupivacaine was incrementally injected to achieve a T10 sensory level, and analgesia was maintained using a continuous infusion of 0.0625% bupivacaine with fentanyl. Nine days post-delivery, the patient developed back pain radiating to her right leg, but she was otherwise asymptomatic. She was afebrile; with a slightly tender, non-erythematous, non-draining, 1 cm nodule at the epidural catheter site. Motor and sensory examinations were normal at that time. However, the patient returned 24 hr later and further investigations revealed: WBC 17,800.mm(-3), platelets 486,000.mm(-3), erythrocyte sedimentation rate 50 mm.hr(-1), and C-reactive protein 8.8 mg.dL(-1). The magnetic resonance imaging demonstrated an EA at the L(3-4) level causing minimal cord compression. The patient underwent an emergency decompressive laminectomy. Cultures revealed methicillin-sensitive Staphylococcus aureus. Her pain improved, and she was discharged on the third postoperative day with a six-week course of iv ceftriaxone. CONCLUSION: Causative organisms for EAs include coagulase-negative Staphylococci, S. aureus, and Gram-negative bacilli. Infection can occur either hematogenously or by direct contamination during catheter placement. Risk factors include immunocompromised states and PUPPP, as with the case of this patient.

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PURPOSE: To describe the impact of maternal automatic implantable cardioverter-defibrillator (AICD) therapy on pregnancy outcome, and discuss the clinical rationale for regional anesthesia in parturients with AICDs. CLINICAL FEATURES: A 20-yr-old primigravida with a history of familial cardiomyopathy and AICD placement presented at 39 weeks gestational age for elective labour induction. Ultimately, the patient underwent a Cesarean section for a failed induction. Her AICD was deactivated during the peripartum period, although the pacing function remained active as she had an underlying heart rhythm of less than 34 beat.min(-1). The patient had continuous electrocardiogram monitoring via an external defibrillating unit to which she remained connected by external defibrillator pads. Labour analgesia and surgical anesthesia were provided with a lumbar epidural dosed with varying concentrations of bupivacaine. This management resulted in an excellent maternal and fetal outcome. CONCLUSIONS: Automatic implantable cardioverter-defibrillators are being utilized more frequently in the obstetric population, and appear compatible with good fetal outcomes. Experience with the anesthetic management of these patients is markedly limited - primarily involving reports of general anesthesia for Cesarean section. Epidural anesthesia, however, offers distinct advantages in this patient population including easy conversion from labour analgesia to surgical anesthesia, preservation of fetal-maternal hemodynamics, prevention of increases in plasma catecholamines due to labour or operative pain, and, finally, possible direct suppression of arrhythmias by pharmacologically-active plasma levels of local anesthetic.

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PURPOSE: To explain the considerations governing the anesthetic management of pregnant patients with Klippel-Trenaunay syndrome (KTS). Klippel-Trenaunay syndrome is a congenital vascular disease characterized by cutaneous hemangiomas, venous varicosities, and limb hypertrophy; and is associated with both hemorrhagic and thrombotic complications. The importance of this diagnosis, including the presence of neuraxial vascular anomalies, is often under-appreciated by both obstetric and anesthesia providers. While regional anesthetic management of patients with KTS has been discussed by others, we present a case in which regional anesthesia presented an unwarranted risk to the patient. CLINICAL FEATURES: An obese, 18-yr-old parturient with a fetus in the breech position underwent Cesarean delivery at 35 weeks gestation secondary to evolving preeclampsia. Unfortunately, no neurovascular imaging of this patient's spine was available. The patient underwent an attempted external cephalic version, a failed obstetric induction, and, ultimately, a Cesarean delivery under general anesthesia. The resulting infant was without any stigmata of KTS. Both mother and infant did well during the course of their hospitalization, and were discharged home without incident. CONCLUSIONS: The posterior cutaneous hemangiomas of KTS may be associated with underlying epidural and subdural vascular malformations. Disruption of these vascular anomalies during regional anesthesia may lead to neuraxial hematoma formation, which may be further compounded by a consumptive coagulopathy observed in some cases of KTS. If neuraxial vascular anomalies cannot be ruled out radiographically, regional anesthesia should be avoided. Additionally, regardless of the anesthetic technique chosen, the coagulation profile of these patients should be verified for signs of coagulopathy.

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