Ultrasound guided epidural analgesia for labor in a patient with an intrathecal baclofen pump

With increasing popularity of intrathecal drug delivery systems such as baclofen and opioids for management of chronic pain conditions, it is not uncommon for an obstetric anesthesiologist to encounter such a patient in the labor and delivery suite. A 44-year-old G1P0 female (177 cm, 88 kg) with left spastic hemiplegia and central post-stroke pain syndrome presented at the pre-anesthesia evaluation clinic to discuss her anesthesia options for labor and delivery. Past medical history included a middle cerebral artery infarct due to an embolus from a patent foramen ovale. An intrathecal baclofen pump (ITBP) was implanted to control the residual left-sided spasticity and neurological pain. An abdominal radiograph showed a subcutaneous infusion pump over the right lower abdominal quadrant with tubing coiling posterior to the L2–3 spinous processes, entering the spinal canal between L3-4 spinous processes and terminating caudal to T8–9 interspace (Fig. 1). The neurosurgeon who placed the ITBP was consulted. Labor epidural insertion was planned early in labor. Ultrasonography of lumbar spine (transverse and longitudinal views) was used to determine epidural depth and to ensure the pump catheter was not in the pathway of Tuohy needle placement. After successful epidural placement on the first attempt, a patient-controlled epidural analgesia (PCEA) infusion of local anesthetic and opioid was started in active labor. Labor progressed normally and she was satisfied with her analgesia.