Background
Buerger’s disease (BD) or thromboangiitis obliterans is an inflammatory occlusive vascular disease affecting small and medium vessels in the distal upper and lower extremities [1]. Since BD often develops in men, it is extremely rare for a pregnant patient to be complicated with BD [1]. A literature review on PubMed only revealed 4 other case of BD in pregnant patients.

Case Presentation
A 40-year-old multigravida with previous caesearean delivery presented to the obstetric clinic at 34 weeks gestation for premature rupture of membrane and subsequently labour pain. She is a smoker with BD and gestational diabetes on diet control. She was on enoxaparin and aspirin but stopped 3 months and 2 days ago respectively. An urgent category 3 Caesearean delivery was planned. After anaesthetic consult, the patient opted for general anaesthesia, due to concerns on small risk of spinal haematoma due to aspirin. She underwent rapid sequence induction with cricoid pressure, 250mg thiopentone and 100mg succinylcholine with easy intubation and airway was secured with size 7 endotracheal tube. She received intravenous 10mg morphine and patient controlled morphine analgesia for postoperative pain relief. She was able to breastfeed, ambulate and was discharge well on the 3rd postoperative day.   

Discussion 
In patients who are receiving anticoagulants, there may be higher bleeding risk and spinal anesthesia may be contraindicated depending on the type of anticoagulant the patient is on. Other considerations for patients with BD includes difficulty in intravenous and intra-arterial line insertion. BD can affect cerebral, coronary, renal and mesenteric vessels as well [2]. Consequently, patients may also be at increased risk of cerebral or myocardial infarction. In one reported case, where the pregnancy was complicated with intrauterine growth restriction, the placenta was found to have multiple infarcts and calcifications histologically. As such, it is important to be aware of potential foetal compromise.

References
1.	Kikuchi N, et al.(2006). Int J Gynaecol Obstet. 94(1):62-6
2.	Aszalos C, et al. (2016). Orv Hetil. 157(30):1207-11. 

Learning points
BD is extremely rare in pregnant patients.  They may be on anticoagulants which could be a contraindication to regional anaesthesia. Careful management of obstetric patients with BD is important as it can lead to maternal and foetal compromise. 


06 / Caesarean delivery in pregnancy complicated by Buerger’s disease