Department of Anaesthetics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.
Forth Valley Royal Hospital, Stirling Road, Larbert, United Kingdom.
Int J Obstet Anesth. 2024 Nov;60:104232. doi: 10.1016/j.ijoa.2024.104232. Epub 2024 Jul 17.
The peripartum management of obstetric patients with Chiari type I malformation remains a challenge due to the degree of cerebellar tonsillar herniation and a paucity of published evidence. There is concern about neuraxial anaesthetic blocks and uncertainty regarding the optimum mode of delivery. We systematically searched the literature for the obstetric management of patients with Chiari type I malformation, independent of publication date and language. We also searched our local hospital database from December 2009 to December 2022 for all deliveries to patients with this condition. We identified 137 cases comprising 103 deliveries described in 40 publications that met our inclusion criteria; 34 deliveries were identified in our local database. There were 84 spontaneous vaginal deliveries, 52 caesarean deliveries, and one delivery by unknown modality. Sixty neuraxial blocks were performed; approximately half of these were epidural procedures for labour analgesia. Six patients had new or worsened symptoms following delivery, but it is unclear whether these were related to their Chiari malformation. We identified no cases with brainstem herniation or severe symptoms. We discuss our findings in relation to other published literature and address the concerns described. Our review reveals the use of a variety of modes of delivery and anaesthetic techniques and that most patients suffered no neurological complication. We conclude there is no of evidence to avoid any one approach to labour analgesia, delivery and anaesthesia. We propose a holistic, individualised and patient-centred approach with an appraisal of the risks and benefits to support shared-decision making.
由于小脑扁桃体疝的程度以及发表的证据有限，产科患者 Chiari Ⅰ 型畸形的围产期管理仍然是一个挑战。人们担心脊神经麻醉阻滞，并对最佳分娩方式存在不确定性。我们系统地搜索了文献，以了解 Chiari Ⅰ 型畸形患者的产科管理情况，而不受出版日期和语言的限制。我们还从 2009 年 12 月至 2022 年 12 月在我们当地医院的数据库中搜索了所有患有这种疾病的患者的分娩情况。我们确定了 137 例病例，其中 103 例分娩情况在 40 篇符合纳入标准的出版物中有描述；在我们当地的数据库中发现了 34 例分娩情况。其中有 84 例自然阴道分娩、52 例剖宫产分娩和 1 例未知方式分娩。进行了 60 次脊神经阻滞；其中大约一半是用于分娩镇痛的硬膜外程序。6 名患者在分娩后出现新的或恶化的症状，但尚不清楚这些症状是否与 Chiari 畸形有关。我们没有发现脑干疝或严重症状的病例。我们根据其他已发表的文献讨论了我们的发现，并解决了描述的问题。我们的综述揭示了使用各种分娩方式和麻醉技术，并且大多数患者没有出现神经并发症。我们得出的结论是，没有证据表明应避免任何一种分娩镇痛、分娩和麻醉方法。我们建议采用整体、个体化和以患者为中心的方法，评估风险和收益，以支持共同决策。
