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An atypical presentation of placental abruption as neck and shoulder pain
Abstract Number: F-05
Abstract Type: Case Report/Case Series
Placental abruption (PA) complicates about 1% of pregnancies and is an important cause of perinatal mortality and morbidity. (1) Patients with PA classically present with painful vaginal bleeding. However 20% of women may present with concealed bleeding (2), and labor epidural analgesia may attenuate abdominal pain associated with PA. We present the anesthetic management of a woman who received epidural labor analgesia and developed an atypical presentation of neck pain associated with PA.
A 38 year-old, G1P0 woman with mild preeclampsia at 37+3 weeks gestational age presented to our institution for induction of labor (IOL). Two hours after IOL, the patient requested a labor epidural. A combined spinal-epidural (CSE) was placed at L3-L4 interspace without difficulty. Four hours later, she reported no pain and had approximately T8 level to cold without motor block. Six hours post-CSE placement, she complained of sudden onset, 10/10 mid-neck and bilateral shoulder pain. Her heart rate increased to 130 bpm and blood pressure was 150/70. The fetal tracing demonstrated two late decelerations, and cervical exam indicated she was remote from delivery. As a result, her OB requested urgent cesarean delivery for presumed worsening preeclamptic disease. The epidural was incrementally dosed with a total of 12 ml of 2% lidocaine with bicarbonate and epinephrine to achieve T4 level for cesarean delivery. Concurrently, midazolam 0.5mg was dosed incrementally to a total of 2mg to treat presumed muscle spasm and to alleviate distress due to continued neck pain. Decision-to-delivery time was 11 minutes and the baby’s APGARs were 7 and 9 at 1 and 5 minutes, respectively. A large placental abruption with leakage of blood into the peritoneal cavity via both Fallopian tubes was observed intraoperatively. The patient's shoulder and neck discomfort resolved completely upon delivery. Both infant and mother were discharged home without complication on postoperative day 4.
Referred pain from diaphragmatic irritation, experienced in the shoulders and neck, is a well-described entity with a wide range of etiologies including gastric, splenic, cardiac, and pulmonary pathology. Severe shoulder pain has been described in a pregnant patient with uterine rupture and dense epidural block. (3) In our case, pain was initially presumed to be secondary to muscle spasm. Instead, the patient likely experienced referred pain caused by diaphragmatic irritation from tracked blood in the peritoneum. Our case highlights the importance of considering PA as a cause of atypical pain in patients with a functioning epidural for labor analgesia.
1) Obstet Gynecol 2006;108:1005-16.
2) Obstet Gynecol Surv 2002;57:299-305.
3) Int J Obstet Anesth 2012;21:200-1.