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Opioid-Only Epidural Analgesia: An Alternative to Controlling Pain in the Preterm Obstetric Patient with Stalled Cervical Dilation
Abstract Number: F-64
Abstract Type: Case Report/Case Series
Case: A 19 year old G2P0101 at 34w3d gestation was admitted with preterm labor and advanced cervical dilation. Her PMH was significant for a previous preterm delivery and an anaphylactic reaction to morphine. As the obstetricians felt labor was progressing, epidural analgesia was initiated with 0.0625% bupivacaine and 2 mcg/mL fentanyl. After 24 hours, membranes were still intact, her cervix stopped changing and frequency of contractions decreased. The OBs requested epidural discontinuation, as they felt the patient was no longer in active labor. The epidural infusion was stopped and catheter left in place in case patient began laboring again. Later, the patient complained of constant severe contraction pain, but her cervix remained unchanged. Placental abruption, intraabdominal pathology and infectious causes were ruled out. Despite no contraindication, she was unwilling to utilize oxycodone due to her morphine allergy.
The obstetrician requested assistance in providing analgesia, but did not want patient to require bedrest or continuous fetal monitoring, as the plan was to transfer to antepartum. An opioid-only epidural infusion of hydromorphone was initiated at 120 mcg/hr after an 800 mcg loading dose. This controlled the patient’s pain within 30 minutes with no changes noted on FHR tracing. Five hours later, the infusion was stopped as the pain had resolved. The epidural catheter was capped, and the patient was transferred to antepartum. She went on to deliver a healthy preterm infant without further epidural analgesia.
Discussion: This case highlights an alternative method for controlling pain in the non-laboring obstetric patient without requiring bedrest or continuous fetal monitoring. Local anesthetics are well known to cause lower extremity weakness which can confine the patient to bed. Studies in postoperative patients have shown decreased motor blockade and decreased hemodynamic instability with opioid only analgesia (1). Epidural hydromorphone provides similar pain relief but has decreased onset time as compared to morphine (2).
There is no current standard for epidural hydromorphone dosing. In post cesarean section patients a 1 mg bolus dose provided at least 6 hours of pain relief (1). Regarding epidural infusions, 30 to 40 mcg/hr hydromorphone plus a dilute dose of local anesthetic seems to provide effective analgesia with minimal adverse effects in laboring patients (3). Neuraxial hydromorphone can be utilized with or without local anesthetics to provide safe and effective pain control in obstetric patients (1).
1. Perioperative Medicine and Pain, Vol 19, No 2 (June), 2000: pp 108-131
2. Canadian journal of anesthesia, Vol 43, Issue 6 (June), 1996: pp 595-598
3. Anesthesia & Analgesia, Vol 94, Issue 5 (May), 2002: pp 1310-1311