Case report: Anaesthetic management of a labouring parturient with Brugada Syndrome
Brugada syndrome is an autosomal dominant ion channelopathy affecting cardiac sodium ion channels, which may lead to ventricular tachyarrhythmias and ultimately sudden cardiac death [1]. The syndrome may be unmasked by drugs used perioperatively, fever, surgical insult and vagal stimulation [2] . Local anesthetics with slow dissociation characteristics such as bupivacaine, have been discouraged due to concerns regarding unmasking the Brugada phenotype and potential precipitation of ventriular tachyarrythmias. Evidence suggests lignocaine is safe when used in low dose [3,4].
A 19 year old primigravida with Type 1 Brugada Syndrome was referred in early pregancy for anaesthesia assessment. Following multidisplinary team review, consensus regarding anaesthesia management in labour was agreed (remifentanil PCA, followed by combined spinal epidural (CSE) if required). Limited dose of bupivacaine with avoidance of background bupivacaine infusion was advised. Intermittent epidural top-up of lignocaine would be given as needed.  At 38 weeks gestation the patient presented with lower abdominal pains. Following induction of labour remifentanil PCA was commenced. When analgesia became unsatisfactory, a CSE was performed. Intrathecal bupivacaine 2.5 mg with fentanyl 20 mcg initially provided adequate analgesia with no untoward effect. Subsequent epidural top-ups of 5mls of 1% and 2% lidocaine failed to achieve satisfactory analgesia. Following unsuccessful CSE replacement, a repeat single intrathecal dose was administered for patient distress. The patient shortly delivered a healthy baby boy. No peripartum cardiac arrhythmias were recorded. 
Brugada labouring parturients pose significant anaesthetic challenges. Evidence suggests that low dose bupivacaine is not a contraindication. Intrathecal bupivacaine for analgesia or caesarean delivery appears safe and should be considered.

Anaesthetic management of a labouring parturient with Brugada syndrome