Consequences of spine imaging associated with guideline non-adherence in a pregnant patient with hereditary haemorrhagic telangiectasia

Abstract

A pregnant woman with hereditary haemorrhagic telangiectasia was referred to the obstetric anaesthetic team to determine the safety of neuraxial labour analgesia. International guidelines state that the risk of complications from spinal vascular malformations during neuraxial procedures is theoretical and recommend against routine imaging of the epidural space in asymptomatic patients. Despite this, magnetic resonance imaging was obtained to provide patient reassurance. Supine imaging was interpreted as showing an epidural arteriovenous malformation. A repeat scan in the lateral position demonstrated resolution of the apparent lesion, consistent with dynamic pregnancy-related engorgement of the epidural venous plexus due to inferior vena cava compression rather than true malformation. The initial interpretation led to the patient being incorrectly informed that neuraxial analgesia or anaesthesia were contraindicated, resulting in delayed epidural placement, inadequate labour analgesia and considerable anxiety. She ultimately received combined spinal-epidural analgesia, underwent urgent caesarean birth and recovered fully after transient postpartum femoral neuropathy; a third magnetic resonance imaging scan confirmed the absence of epidural haematoma. This case illustrates that non-adherence to guidelines and unnecessary imaging can create diagnostic confusion, delay effective treatment and expose patients to avoidable distress and additional investigations.