Background and aims Term achondroplastic parturients may have cephalopelvic disproportion resulting in lower section cesarean section (LSCS). Premature ossification of bones results in characteristic craniofacial abnormalities and is associated with atlanto-axial instability and macroglossia leading to difficult airway. With pregnancy, airway oedema and reduced functional reserve capacity further complicate intubation. Central neuraxial blockade (CNB) is challenging due to potential kyphoscoliosis, spinal stenosis, unpredictable spread of local anaesthetics in central neural space and uncertainty of dose due to disproportionate spinal column to overall height. In this case, surgical factors included prolonged operation with dense adhesions and potential postpartum haemorrhage.

Methods 33-year-old, G3P2, 36 weeks gestation, with achondroplasia (height 126 cm, weight 44 kg), unbooked and unfasted, presented for emergency caesarean section (LSCS) for 2 previous LSCS in labour. She had disproportionately short limbs to spinal column height. Airway assessment showed potential difficult airway with small mouth opening, macroglossia and receding chin. She denied neck or back problems. Previous anaesthetic chart showed that a single shot spinal with 2.1 ml of 0.5% heavy bupivacaine requiring 1 g phenylephrine over 60 minutes and receding block requiring supplementation of analgesia near the end.

Results Two attempts at combined spinal-epidural (CSE) was done with 1.5 ml of 0.5% heavy bupivacaine, achieving a sensory height of T2 before skin incision. 35 minutes later, she required epidural top up with 13 ml of 2% lignocaine in titrated boluses and IV ketamine 20 mg due to discomfort. Surgery ended uneventfully after 100 minutes.

Conclusions We recommend CSE in parturients with achondroplasia for LSCS to allow titration of CNB.