Labor Analgesia in unrepaired Chiari Type I

[scotchnwater]

From a recent weekend on call in L&D:

37 yo G2P1 at term requesting a labor epidural. Nurse calls me to ask for the epidural and adds: "you may want to bring your attending, she has that Arnold thing". I check her record and there is one small reference to a Chiari malformation in her PMHx.

In speaking with the patient, she appears to have an unrepaired, symptomatic Type I Chiari malformation, diagnosed within the past 2-3 years after she complained of HA, back pain, and BUE numbness/tingling. There is no workup in her chart as she apparently had this diagnosed elsewhere and we don't have immediate access to any of these records. She denies ever having any surgery to repair this.

Pt states she had an uneventful labor epidural with her first child 15 years prior and would really like one NOW.

Do you put in the epidural? What type of discussion do you have with the patient in regards to risks, benefits, alternatives?

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[Planktonmd]

From a recent weekend on call in L&D:

37 yo G2P1 at term requesting a labor epidural. Nurse calls me to ask for the epidural and adds: "you may want to bring your attending, she has that Arnold thing". I check her record and there is one small reference to a Chiari malformation in her PMHx.

In speaking with the patient, she appears to have an unrepaired, symptomatic Type I Chiari malformation, diagnosed within the past 2-3 years after she complained of HA, back pain, and BUE numbness/tingling. There is no workup in her chart as she apparently had this diagnosed elsewhere and we don't have immediate access to any of these records. She denies ever having any surgery to repair this.

Pt states she had an uneventful labor epidural with her first child 15 years prior and would really like one NOW.

Do you put in the epidural? What type of discussion do you have with the patient in regards to risks, benefits, alternatives?

No Epidural.
Although some people might do it.
Look at this old thread:
http://forums.studentdoctor.net/archive/index.php/t-480487.html

 

[rsgillmd]

I'm a big fan of regional, but with a symptomatic patient and no imaging to assess severity or other problems, I wouldn't place an epidural.

I had a patient recently who had an MRI (several months prior to me seeing her) while having numbness/tingling in hands and weakness in the right arm, but minimal headache at that time. Now the headaches had worsened. A review of the MRI report showed significant cervical cord compression.

The point: beware of what may lurk beneath in patients who have more than just headaches.

Just because your patient had an epidural previously without problems, while reassuring, does not really mean much. If I jump off the Brooklyn Bridge and survive, does that mean I can get back on and jump again safely?

So long story short, based solely on the history that you have given and assuming you did not anticipate a difficult airway, I would not give this patient an epidural.

 

[periopdoc]

IIRC the thread ended in a stalemate with most of the PP guys saying they would give it a go and put the damn epidural in.

You could always use a remifent pca for labor and GA for section.

- pod

 

[scotchnwater]

So here's what I did:

Called the attending and had a discussion with him and then curbsided Neurosurgery who said that while an epidural itself would be fine "it had better be perfect". They reiterated the badness that could ensue with a wet-tap.

I then talked with the patient and explained to her the risk of the wet-tap (which approaches 2% at our institution on L&D), and offered my opinion that the benefit did not justify the (albeit small) risk.

When she asked why the epidural worked fine the last time (before her diagnosis of Chiari), I told her she was fortunate everything turned out ok but there was a chance even then that things might have not gone so well - and that furthermore now that we had this information it made us less-than-excited about proceeding with neuraxial.

Then I wrote the orders for the Remi PCA (which worked great until that last hour or so of labor...).

 

[epidural man]

No Epidural.
Although some people might do it.
Look at this old thread:
http://forums.studentdoctor.net/archive/index.php/t-480487.html

After reading that, I'm very confused. So I give beta blockers for Chiari Type I if I'm going to place an epidural?

 

[epidural man]

You could always use a remifent pca for labor and GA for section.

- pod

Probably should do that for almost everyone and forget the epidural. I'd get more sleep.