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Cerebral arteriovenous malformations (AVMs) are rare and complex, focal, congenital, and vascular anomalies in which arterial blood flows directly into draining veins in the absence of an intervening capillary bed . Normal autoregulation of the cerebral blood flow occurs through vascular resistance created by blood vessels of smaller diameter, such as arterioles and capillaries . AVMs lack this crucial vascular organization leading to marked increased blood flow to the affected region. Easily recognized tortuous and dilated blood vessels are pathognomonic of AVMs

Here, described a successful anesthetic management of a patient with a large AVM involving the cervicomedullary (CM) junction in active labor. A 20-year-old patient with intrauterine pregnancy at 38 weeks and 1 day of gestation was urgently admitted for primary cesarean section (CS) secondary to active labor. Prenatal care complications included maternal CM AVM. Previous neurosurgery evaluation contraindicated spontaneous vaginal delivery due to increased risk of rebleeding. A neurosurgical evaluation was necessary due to her past medical history. After being evaluated, Neurosurgery suggested that vaginal delivery should be avoided due to the elevated risk of AVM rupture during labor maneuvers. At that time, CS was indicated and scheduled at 39 weeks of gestation by the Obstetrics team. The patient’s prenatal care was uneventful.

One week before the scheduled CS, the patient presented to the Obstetrics Emergency Department in active labor. She was immediately transferred to the Labor and Delivery Unit. Preoperative evaluation was remarkable only for the history of brainstem AVM that bled three years before the current admission. The patient and her family understood all risks of the procedure and agreed with a placement of a combined spinal continuous lumbar epidural. The procedure was uneventfully performed in the operating room after standard American Society of Anesthesiologists monitors were placed. It consisted of an intrathecal injection of 20 µg of fentanyl and slow and gradual epidural injection of lidocaine 2% without epinephrine through the lumbar epidural catheter. The total amount of local anesthetic administered was 14 ml (280 mg) in 25 minutes, reaching T5 level. The CS and the postoperative period were unremarkable. At the end of the surgical procedure, 2 mg of morphine was injected in the epidural space followed by uneventful epidural catheter removal.

Postoperative pain control was done with morphine patient-controlled analgesia (PCA) indicated and managed by the primary team. Tubal ligation was discussed with the patient who refused it. During that admission, Neurosurgery reevaluated the patient, but there were no new suggestions. The patient was discharged home on the postoperative day 8 without complications.

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