Reactions 1436 - 26 Jan 2013

SBupivacaine/fentanyl

Uterine hypertonicity leading to placental abruptionand fetal bradycardia: case report

A 26-year-old pregnant woman developed uterinehypertonicity leading to progression of placental abruption andfetal bradycardia following combined spinal-epidural analgesia(CSE) with bupivacaine, fentanyl and tests doses of lidocaineand epinephrine [adrenaline].

The woman presented in active labour at 38 weeksgestation. Examination revealed a bloody show, but nointervention was warranted. Due to intense pain, sherequested epidural analgesia. CSE was performed withinjections of bupivacaine 2.5mg and fentanyl 25µg into theintrathecal space, as well as a 3mL test dose of lidocaine 1.5%and epinephrine 15µg via epidural catheter. Within 5 minutes,the tocometer revealed uterine contractions that had notreturned to baseline. Eleven minutes after intrathecal injection,the fetal heart rate decreased to 100 beats/min.

The woman was placed in the decubitus position, andreceived oxygen. The fetal heart rate did not improved.Examination revealed a rock hard uterus with a sustainedcontraction. She received terbutaline, which decreased theuterine tone. She underwent artificial rupture of the amnioticmembranes, which revealed overt blood. Fetal bradycardiaworsened, and she was transferred to the OR for emergencycaesarean delivery under general anaesthesia. She delivered afemale baby with Apgar scores of 8 and 9 at 5 and 10 minutes,respectively. Examination and pathology confirmed thediagnosis of placental abruption. Due to uterine atony, shereceived oxytocin, methylergometrine and carboprost. Heruterine tone improved, and bleeding was controlled followingsurgery. The episode of bloody discharge prior to CSE wasthought to suggest pre-clinical placental abruption. Themother and baby were subsequently discharged in excellentcondition.

Author comment: "This report documents a case ofplacental abruption and fetal bradycardia which occurredsoon after initiation of CSE analgesia in a patient with aprevious bloody show. . . We hypothesize that this bloodyshow might have indicated a sub-clinical placental abruption.If so, it is possible that uterine hypertonicity secondary to CSEanalgesia might have contributed to progression of theabruption."Jaime F, et al. Placental abruption occurring soon after labor combined spinal-epidural analgesia. International Journal of Obstetric Anesthesia 21: 376-379, No.4, Oct 2012. Available from: URL: http://dx.doi.org/10.1016/j.ijoa.2012.07.002 -USA 803082430

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Reactions 26 Jan 2013 No. 14360114-9954/10/1436-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved