Neuraxial Techniques for Parturients with Thromboprophylaxis or Thrombocytopenia.

Pharmacologic thromboprophylaxis from venous thromboembolism (VTE) and thrombocytopenia in pregnancy results in conditions that may preclude the use of neuraxial anesthesia due to a perceived risk of spinal/epidural hematoma. Spinal epidural hematoma is a recognized complication in patients who are hypocoagulable and may lead patients to undergo general anesthesia for delivery or other procedures, which carries numerous complications in obstetric care. A robust understanding of maternal physiologic changes in coagulation status, review of consensus statements, and safety bundles may help to maximize the use of neuraxial anesthesia in obstetric patients who might otherwise be denied these anesthetic techniques.

Usefulness of intrapartum magnetic resonance imaging for a parturient with neurofibromatosis type 1 during induction of labor for preeclampsia.

A 22-year-old woman, G3P0 at 31 weeks, 1 day gestational age, was admitted to the labor and delivery unit for induction of labor (IOL) due to preeclampsia with severe features. Her medical history included neurofibromatosis type 1 (NF-1) and systemic lupus erythematosus with pericarditis and pericardial effusion. When labor analgesia was considered, the concern for an undiagnosed spinal neurofibroma and attendant sequelae was deliberated. After a multidisciplinary discussion, the IOL was halted during the cervical ripening phase to allow timely magnetic resonance imaging (MRI) of the spine. The MRI was negative for spinal lesions and the patient subsequently received labor analgesia via a combined spinal-epidural catheter.

Anesthetic management for cesarean section and tubal ligation in a patient with Marfan syndrome, multiple sclerosis, and multiple postdural puncture headaches.

We report a 29-year-old woman with Marfan syndrome, multiple sclerosis, and multiple postdural puncture headaches who presented for a scheduled repeat cesarean delivery with bilateral tubal ligation at 37 weeks gestation. During an outpatient preoperative visit, a general anesthetic plan was ultimately selected through a shared decision-making process. The patient had an uneventful general anesthetic that included a rapid sequence induction with direct laryngoscopy. Neonatal Apgar scores were 8 at 1 minute and 9 at 5 minutes. Prior to emergence, fentanyl, acetaminophen, and ketorolac were administered intravenously and a transversus abdominus plane block was performed. On the first postoperative day, the patient expressed satisfaction with the anesthetic plan and, in particular, the avoidance of a neuraxial technique and postdural puncture headache. The patient was discharged on the second postoperative day with no apparent sequelae. A neuraxial anesthetic technique is usually preferred in patients undergoing cesarean delivery, and it is safe to perform this technique in patients with either Marfan syndrome or multiple sclerosis. We formulated an anesthetic plan that honored our patient's autonomy and produced a good maternal and neonatal outcome.