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Traumatic Epidural Catheter Removal in a Laboring Patient with Acute Psychosis
Abstract Number: F 43
Abstract Type: Case Report/Case Series
Introduction: The prevalence of postpartum psychosis is 1:1000; intrapartum it is unknown.(1) Acute psychosis can have negative consequences for mother and fetus. We present an acutely psychotic laboring patient who traumatically removed her epidural and IV prior to delivery.
Case report: A 27 y/o G3P1 presented at 40 wks with gestational HTN for IOL. PMH included hepatitis C, cocaine and heroin abuse (methadone maintenance), anxiety, and depression (no meds). She became “stiff” to antipsychotics in the past. After receiving an epidural, our patient became very agitated upon visualization of a bloody show. She ripped out her IV and epidural and ran through the labor ward naked, repeatedly banging her head against the wall until physically restrained. Psychiatry recommended treatment with IM medications including haloperidol, lorazepam, and diphenhydramine. She remained agitated and combative, eventually delivering a healthy boy by SVD (APGARs 8,9). Her psychosis rapidly resolved. A head/spine CT ruled out acute spinal/intra-cranial injury. CPK rose to 5000 μg/ml, presumably from physical exertion, restraining efforts, and possibly a mild neuroleptic malignant syndrome (NMS) reaction. The entire epidural catheter was located in three pieces at two separate locations on the L&D ward. She was discharged home on POD#2 with a diagnosis of Psychosis NOS (Not Otherwise Specified).
Discussion: Acute psychosis during labor is not well studied. Untreated depression during pregnancy can have deleterious effects on mother and baby. These include a higher incidence of gestational HTN/preeclampsia, smoking, cocaine, and alcohol abuse, more painful labors and increased use of labor analgesia (higher catecholamine levels), higher rates of instrumentation and C-section, and more SGA babies (lower APGARs, higher NICU admissions).(2,3) Depressive symptoms can worsen leading to acute psychosis.
With no IV or epidural, sedation and labor analgesia were limited. Despite our patient’s prior reaction to antipsychotics, she received IM haloperidol, lorazepam, and diphenhydramine. Fetal side effects include sedation, hypotonicity, and lower APGAR scores. Elevated CPK post delivery may have been a mild NMS reaction from haloperidol, although no muscle rigidity or elevated temperature developed. IM ketamine is also an option for sedation or GA for C/S but may exacerbate psychosis.(4)
Traumatic epidural catheter removal can cause serious sequelae including retained catheter pieces, infection, arachnoiditis, and other neurologic problems. Locating the entire epidural catheter, albeit in pieces, avoided CT/MRI imaging. Management of a retained epidural catheter piece includes monitoring for neurologic symptoms, signs of infection, and possible surgical removal.(5)
1. BJP 1998;172:521-26
2. CJP Nov 2004;49:726-35
3. Psychosom Med 2001;63:830-4
4. Neuropsychopharmacology 1995;13:9-19
5. J of Clin Anesth 2007;19:310-14