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Abdominal Muscle Wall Rupture in Pregnancy
Abstract Number: SUN-65
Abstract Type: Case Report/Case Series
The transversus abdominis plane (TAP) block is a regional anesthetic technique indicated for of the abdominal wall after surgery. We present the successful nontraditional use of a TAP catheter to treat pain associated with acute internal oblique muscle rupture in a laboring pregnant woman.
A 28 year old otherwise healthy G1P0 patient at 38 weeks and 6 days gestation on the midwife service presented to the OB triage unit in early labor with onset of acute right-sided abdominal pain. Exam was notable for severe anterior R sided abdominal pain with swelling and a boggy fluid collection to the right of the umbilicus. Diagnostic ultrasound demonstrated a ruptured internal oblique muscle and a large fluid collection within the capsule of the muscle. She was admitted to Labor and Delivery for induction of labor in the setting of an acute muscle rupture. Though her labor pain was quite tolerable, her anterior abdominal wall pain was severe. Not long before admission she and her husband attended a birthing class where they decided to use nitrous oxide as her primary means of pain control for labor and did not desire an epidural. In line with her values, we placed a TAP catheter which after bolus-dose ropivacaine resulted in almost complete resolution of her anterior abdominal wall pain within 45 minutes. The patient maintained the ability to ambulate, use the restroom, remain un-monitored, and without a foley catheter which coincided with her desires in her birth plan. We maintained her analgesia using bolus-dose ropivacaine every 4 hours. She continued to labor on an oxytocin infusion utilizing nitrous oxide for labor analgesia for 28 more hours until her labor pain grew so severe that she desired epidural anesthesia. After placement of epidural she labored 20 hours more until declared failure to progress and underwent cesarean section. Post-operatively her anterior abdominal pain resolved spontaneously. The TAP catheter was removed at time of discharge.
Transversus abdominis plane block is primarily indicated for post-operative analgesia as part of a multimodal approach in abdominal surgery. Though this is not a previously well-described indication, the TAP block was particularly suitable in treating this patient’s chief complaint because her anterior abdominal pain only involved the cutaneous nerves of the abdomen. It is important to distinguish that this patient’s primary chief complaint was anterior abdominal pain and was truly distinct from her tolerable pain of labor. She and her husband felt empowered in the birth experience because the interventions performed happened in a sequential fashion of necessity for the situation that presented at hand.