Neuraxial analgesia in a parturient with the VACTERL association undergoing labor and vaginal delivery

• Published in: Brazilian journal of anesthesiology (Elsevier) 2018-03, Vol.68 (2), p.205-208
• Main Authors: Ramos, Juan A., Shettar, Shashank S., James, Christopher F.
• Format: Article
• Language: eng ; por
• Subjects: Anal Canal - abnormalities; Analgesia, Epidural; Analgesia, Obstetrical; ANESTHESIOLOGY; Clinical Information; Delivery, Obstetric; Dor obstétrica; Epidural analgesia; Esophagus - abnormalities; Female; Heart Defects, Congenital; Humans; Kidney - abnormalities; Labor, Obstetric; Limb Deformities, Congenital; Obstetric pain; Pregnancy; Pregnancy Complications; Spine - abnormalities; Síndrome de Vacterl; Trachea - abnormalities; VACTERL association; Young Adult
• ISSN: 0104-0014; 1806-907X; 0104-0014; 1806-907X
• DOI: 10.1016/j.bjane.2016.05.002

The term VACTERL is an acronym for an association of congenital malformations: including vertebral, anal, cardiac, tracheo-esophageal, renal and limb anomalies. VACTERL anomalies pose a formidable challenge to anesthesiologists. We describe the anesthetic management of a parturient with VACTERL association, who underwent neuraxial analgesia for labor and vaginal delivery. A 23 year old primigravida at 39 weeks gestation presented in labor at 4cm cervical dilatation, completely effaced, requesting labor analgesia. Past medical history included VACTERL association with an imperforate anus and a partial endocardial cushion defect, both repaired in early childhood. She also had significant dorso-lumbar scoliosis with an extra lumbar vertebra. An MRI performed at 14 years age revealed the above findings with no spinal cord abnormalities. With a normal neurologic exam, a combined spinal epidural technique was performed. Despite significant scoliosis, the epidural space was identified at approximately the L3–L4 interspace at a depth of 5cm. Spinal Fentanyl 25mcg was administered followed by continuous patient-controlled epidural analgesia. The patient experienced excellent pain relief throughout her labor, and had an uneventful vaginal delivery 5h after epidural placement. The rarity of VACTERL association in the obstetric population with its extensive anomalies mandates a multidisciplinary approach in the prenatal period as it can pose major challenges to all health care providers, including airway, ventilatory, cardiac and neuraxial problems. This is the first reported case of a successful and safe neuraxial technique in a laboring patient with the VACTERL association with albeit limited vertebral and spinal cord anomalies. O termo Vacterl é um acrônimo para uma associacão de malformacões congênitas que inclui anomalias vertebral, anal, cardíaca, traqueal, esofágica, renal e dos membros (Limbs em inglês). As anomalias Vacterl representam um enorme desafio para os anestesiologistas. Descrevemos o manejo anestésico de uma parturiente com síndrome de Vacterl submetida à analgesia neuraxial para parto normal. Paciente primípara, 23 anos de idade, 39 semanas de gestação, apresentado em trabalho de parto 4cm de dilatação cervical, apagamento completo, exigindo analgesia de parto. A história médica incluía síndrome de Vacterl com ânus imperfurado e defeito parcial do coxim endocárdico, ambos corrigidos na primeira infância. A paciente também apresentava escoliose dors