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The Peripartum Physician: We Can Offer More than Neuraxial Analgesia
Abstract Number: SUN-22
Abstract Type: Case Report/Case Series
A 21-year-old woman, G2, P0, at 23 weeks’ gestation, with a history of gestational trophoblastic disease with lung metastases, was admitted to the hospital with fever, hyperplasia of her gums, and oral mucosal bleeding and a diagnosis of acute myeloid leukemia (AML). On hospital day 15 the obstetric anesthesiology service was consulted to access the patient’s subarachnoid space for intrathecal methotrexate administration in the setting of thrombocytopenia (platelet count 64,000). She was transfused a unit of platelets with a subsequent increase in her platelet count to 84,000, followed by successful dural puncture and deposition of methotrexate into the intrathecal space at the L3-4 interspace with a 22G Whitacre needle. The patient tolerated the procedure well without complication.
Given increasing concern for the development of preeclampsia with severe features, the maternal-fetal medicine service decided to induce labor at 26 3/7 weeks’ gestation. At the start of her induction the patient’s platelet count was 43,000. The patient was counseled regarding our inability to safely provide continuous epidural analgesia, and after a trial of inhaled nitrous oxide we offered systemic analgesia using continuous intravenous ketamine and remifentanil infusions. After obtaining patient consent, we initiated ketamine (3mcg/kg/min) and remifentanil (0.05mcg/kg/min), and we titrated the infusion rates based on the patient’s pain score and sedation level. While sedation scores were not recorded, the ketamine infusion rate was decreased only once during her labor course due to increased somnolence. Her average pain score was a 3/10 and transiently peaked at 6/10 during stage 2, but she tolerated induction and vaginal delivery well and was satisfied with her care.
This case highlights the obstetric anesthesiologist’s role as the peripartum physician, and the potential role of continuous remifentanil and ketamine infusions for labor analgesia in patients with a contraindication to neuraxial analgesia. Without sufficient evidence it is difficult to offer a definitive rule for a “safe” minimum platelet count for insertion of a needle into the neuraxis in patients with thrombocytopenia. However, in this case, access to the intrathecal space was necessary for the patient’s complete chemotherapy regimen given her aggressive AML. As the peripartum physician most acquainted with the obstetric patient’s physiology and potential complications of such a procedure, it is important that obstetric anesthesiologists are involved with the management of critically ill parturients. Finally, our knowledge of analgesic pharmacology is advantageous in offering alternatives to neuraxial analgesia. The use of ketamine and remifentanil infusions, while not standard practice for uncomplicated patients, provides a viable solution to offer effective analgesia and excellent patient satisfaction in patients in whom neuraxial analgesia is contraindicated.