MS and pregnancy

As I recall, spinal local anesthetics have been associated with exacerbations of MS. As of a couple of years ago, I believe the mechanism was thought to be direct toxicity in the demyelinated areas. Spinal narcotics and epidurals have been used safely without problems.

In my mind, the issue is that so many things including surgery, pain, and pregnancy can lead to exacerbation, so it is difficult to pin the blame on the spinal block. I think I would weigh the risks and benefits of the SAB and inform the patient of the options. If the benefit of the SAB was great, I would consider it, but would prefer to avoid it. Time permitting, I would probably use an epidural.

With MS, also don't forget that hyperthermia can also lead to exacerbation.

The other consideration is how advanced the MS is already. If the patient has advanced severe MS, you probably won't make it much worse by doing a spinal.

I will be interested to see what others say.

I'd do it with informed consent.

Otherwise, epidural.

I attended a couple of OB sessions during the ASA meeting this year and this subject came up several times, it seems that the general consensus is that the benefit outweighs the risk in performing regional anesthesia on MS patients for labor and for C sections, although many advise using less concentrated local anesthetics.

I'd have to pile on and agree with the above. But I write an additional progress note that goes into length that the patent is aware and agrees that blah blah blah.

I've heard it both ways, that's the reason why I've asked. We actually recently had a repeat c-section patient who had a spinal the first time, due to urgency of the section, who did fine afterwards. The time she came in (and I saw her) we elected to do an epidural with surgical-level dosing. I asked my attending at the time why not re-do a spinal since she didn't have a problem the first time, and he stated the above reasons already mentioned. I did look it up, and the data seems a bit speculative to me.

The problem, I think, is the waxing/waning nature of MS. If you give a spinal to a patient, and then they immediately have an exacerbation, you're likely to blame the spinal. There could be an entirely different peri-pregnancy mechanism to this. And, I think the mechanistic explanation (direct nerve injury from denuded central axons) is a bit weak.

So, I'd tend to agree with MilitaryMD on this one. If the patient understands the risk, then it's probably okay to proceed with intrathecal. And, you don't run into the problem of failed/inadequate epidural mid-section necessitating GA. Of course, I just have an (indirect) "N" of one. IOW, just my opinion.

-copro

militarymd said:

I'd do it with informed consent.

Otherwise, epidural.

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So when you get informed consent, what do you tell them? You're at an "increased risk" of exacerbation with an intrathecal? How increased? Do patients ask for numbers?

cchoukal said:

So when you get informed consent, what do you tell them? You're at an "increased risk" of exacerbation with an intrathecal? How increased? Do patients ask for numbers?

Click to expand...

I never give out exact percentages. I tell them that I don't know what the exact number is, but that there may be an increased risk.

Then I tell them If I would have something similar done to a member of your own family.

My litmus test is if I wouldn't have something done to me, my wife, or kids, then I wouldn't do it to one of my patients.