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Fentanyl Intravenous Patient Controlled Analgesia During Pregnancy
Abstract Number: S 53
Abstract Type: Case Report/Case Series
A complication of uterine adenomyosis during pregnancy is relatively unknown, because uterine adenomyosis causes infertility. The chief symptom of uterine adenomyosis is severe menstrual pain, and the pain has seemed to reduce under hormonal influence during pregnancy. However, this time, we will present a case report of the patient with severe pain caused by uterine adenomyosis treated by long-lasting intravenous patient controlled analgesia (PCA) by fentanyl.
A 36-year-old woman with uterine adenomyosis was impregnated through in vitro fertilization and embryo transfer. She was admitted with a severe abdominal and sacral pain at 24 weeks gestation. Although she took 60 mg of pentazocine and 400 mg of etodolac per day, they were not effective in the management of her pain. Then obstetrician consulted anesthesiologists. Intravenous PCA by fentanyl was started. Without basal infusion, PCA dose of fentanyl was 25 mcg and lockout interval was 10 minutes. Initially her daily consumption of fentanyl was 500 mcg/day. Daily consumption of fentanyl was decreased to 300 mcg/day by the addition of oral acetaminophen at her 30 weeks gestation.
At 36 weeks gestation, she was performed cesarean section under general anesthesia because the fetal bradycardia was prolonged and uterine rupture was suspected. 300 mg of thiopental, 100 mg of suxamethonium, and 100 mcg of fentanyl were administered for induction. And general anesthesia was maintained by 50 % of oxygen, 50 % of and nitrous oxide, and 1 % of sevoflurane until delivery. Induction-to-delivery time was 2 minutes. A rupture of uterine cervix was detected and cesarean hysterectomy was performed.
APGAR score 1 and 5 minutes after delivery were 8 and 9, and UApH was 7.312. Four days after delivery, her baby was admitted to NICU because of hyperbilirubinemia. However, withdrawal action and neurobehavioral abnormality were not observed. Maternal plasma concentration of fentanyl after induction of general anesthesia was 4.19 ng/mL, and umbilical arterial plasma concentration of fentanyl was 0.307 ng/mL.
Long-lasting pain treatment during pregnancy can be a difficult problem. Care must be taken to ensure adequate pain relief during pregnancy with minimizing the risks to the fetus of teratogenicity, intrauterine withdrawal, or neurobehavioral disorder. The choice of opioid is a critical decision. Actually fentanyl is highly lipid-soluble and it transfers easily from mother to fetus through placenta. However, according to the American Academy of Pediatrics, fentanyl use during pregnancy is compatible. In addition, fentanyl is metabolized to inactive substance unlike morphine, and fentanyl has less adverse effect, especially constipation, than morphine. Moreover, there was a case report of woman who had taken transdermally fentanyl 100 mcg/hour during pregnancy. In our presentation, UA:MA ratio of fentanyl is 0.07, and it seems to have little effect on neonate.