Maternal Arnold-Chiari type I malformation and syringomyelia: a labor management dilemma

Abstract

Arnold-Chiari type I malformations consists of elongation of the cerebellar tonsils with their displacement below the foramen magnum. Syringomyelia is an associated cyst that accumulates cerebrospinal fluid in the cord that can impinge on local nerve fibers. Pregnant women with either of these disorders are of special concern due to the potential risk of brain stem herniation and or spinal column compression from physiological changes that occur during labor. We present two cases. The first case is a patient with syringomyelia who was admitted in labor with worsening peripheral neurological symptoms. Epidural anesthesia was placed and she underwent an uncomplicated cesarean delivery with resolution of her symptoms postpartum. The second case is a patient with an Arnold-Chiari type I malformation and syringomyelia who presented in labor. The patient had an epidural placed and was allowed to progress to complete dilation and effacement at +2 station. She underwent a successful operative vaginal delivery without voluntary maternal expulsive efforts. Both patients had uncomplicated postpartum courses. Although these are rare disorders with significant potential morbidity, labor can be managed by either mode of delivery with careful patient selection. We caution that this review has insufficient numbers of patients to address the safety and efficacy of either delivery mode but rather focuses on alternatives for delivery. This report is the first to document a case of a patient with an Arnold-Chiari malformation and syringomyelia successfully managed in labor with a vaginal delivery.