Labor analgesia in pregnant women with reversible cerebral vasoconstriction syndrome managed with magnesium sulfate infusion to prevent exacerbation and recurrence: two case reports.

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by thunderclap headache with reversible arterial narrowing and may lead to stroke, intracranial hemorrhage, or seizures. Pregnancy and the postpartum period are recognized as high-risk windows, and most reported cases have undergone cesarean delivery because of concern that pain and expulsive efforts might provoke recurrence. Although neuraxial labor analgesia has been described in RCVS, preventive strategies aimed at minimizing intrapartum recurrence have not been emphasized. We describe two pregnant women with a history of RCVS who underwent induction of labor with neuraxial analgesia and planned magnesium sulfate infusion to prevent exacerbation and recurrence of RCVS. In the first case, combined spinal-epidural analgesia was performed with magnesium at 1 g/h, resulting in vaginal delivery without neurological worsening and with stable hemodynamics. In the second case, dural-puncture epidural analgesia was established with magnesium at 1.2 g/h. Cesarean delivery for cephalopelvic disproportion was completed under epidural anesthesia without hemodynamic instability or neurological deterioration. Both patients were discharged without complications. Our experience suggests that neuraxial labor analgesia combined with magnesium sulfate infusion may be a feasible strategy to maintain neurological stability in patients with RCVS, and may broaden delivery options beyond routine cesarean delivery. Further studies are required to determine optimal dosing, timing, and monitoring.