2026 SOAP Annual Meeting

BACKGROUND

Traditionally, pregnancy has been deemed a cause of "difficultairway" due to increased airway edema, reduced functionalresidual capacity, and full-stomach precautions. Furthermore,the physical and hormonal changes during pregnancy lead tohigher risk of aspiration. Gorlin and Sotos Syndromes eachpose challenges to airway and neuraxial management, addingto the changes with pregnancy.

Gorlin Syndrome:

Facial dysmorphism, odontogenic keratocysts,macrocephaly, meningioma, spina bifida, fused vertebrae

Sotos Syndrome:

Intellectual disability, hypotonia, pre-eclampsia,macroglossia, macrocephaly/frontal bossing, mandibularhypoplasia, high-arched palate, pointy chin, scoliosis

CLINICAL FINDINGS

40-year-old G6P3 at 36+5 weeks gestation
Induction of labor for history of pre-eclampsia with severe features
Prominent facial features from Gorlin and Sotos Syndromes
History of meningioma resection and ventricular drain forhydrocephalus prior to pregnancy
Unanticipated difficult airway during meningioma resection two yearsprior (failed direct laryngoscopy, required bougie and indirectlaryngoscopy for intubation)
Two prior vaginal deliveries at outside hospitals, epidural recordsunknown
Stable intracranial pressures throughout pregnancy

Key Considerations:

Concern for contraindications to neuraxial with increased intracranialpressure, possible mass effect, vertebral anomalies
Complex PMH and advanced maternal age increase risk of cesarian section
Known difficult airway and concern for fiberoptic intubation in STAT cesarean section

CLINICAL HISTORY

Meningioma resection two years prior, stable intracranial pressure
Two prior NSVD's at outside hospitals, epidural records unknown
Documented difficult airway

PRESENTATION

Induction at 36+5 weeks GA for pre-eclampsia with severe features
No symptoms of elevated intracranial pressure or mass effect
Mallampati III, large tongue, small mouth opening, mandibular hypoplasia

WORK-UP AND CONSULTS

Neurosurgery: MRI lumbar spine to rule out tethered cord/spina bifida, cleared for neuraxial anesthesia with vaginal delivery
ENT: consulted for flexible laryngoscopy confirming hypertrophied tongue
Trauma surgery: on standby for possible emergent surgical airway

DELIVERY PLAN

Multidisciplinary discussion advocating for early labor epidural
Indirect laryngoscopy and flexible bronchoscopy available for awake intubation

DELIVERY AND POSTPARTUM CARE

Successful placement of dural puncture epidural
Induction of labor with uncomplicated vaginal delivery
Postpartum follow-up with neurosurgery and ENT

DISCUSSION

This case highlights the need for meticulous planning in parturients with known difficult airways and complex comorbidities
Early multidisciplinary planning is essential with thorough work-up if time permits. Image based risk assessment allowedfor safe neuraxial anesthesia
Without an early functioning neuraxial, an emergent cesarean delivery may have required an awake fiberoptic intubation,possibly delaying delivery of the fetus and increasing maternal and fetal risk

TAKE AWAY POINTS

A functioning labor epidural reduced risk of intubation in case of an emergent cesarean section in a patient with a knowndifficult airway and complex medical history

2026 SOAP Annual Meeting

Prepared Before the Push: Peripartum Management in a Parturient with Gorlin and Sotos Syndromes and a Known Difficult Airway

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