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Intentional Overdose of Acetaminophen and Aspirin in a 33 Week Parturient
Abstract Number: F1D-5
Abstract Type: Case Report/Case Series
A 28 y.o. G1P0 at 33 weeks gestation presented after a suicide attempt with 50g of acetaminophen and 5g of aspirin (ASA). She received activated charcoal 1 hr after ingestion. Salicylate and acetaminophen levels were initially below toxic levels, but N-acetylcysteine was started for fetal protective effects. Hematologic studies and ROTEM were within normal limits. 20 hrs after admission, the patient developed muffled hearing; salicylate levels had increased to 14.3mg/dL.
Repetitive fetal heart rate (FHR) decelerations prompted urgent delivery. Cesarean under spinal anesthesia proceeded uneventfully. APGAR scores were 5 and 8. Arterial cord gas was 7.11/49/13/15.6. Maternal postpartum period was unremarkable and laboratory studies normalized 48 hrs after delivery. The neonate developed respiratory distress syndrome and was intubated 4 hrs after delivery and extubated 6 hrs later. Neonatal arterial blood gas was 7.33/40/21 3 hrs after birth and normalized within 10 hrs. Neonatal salicylate level at 24 hrs was 12.6mg/dL; maternal salicylate level 6 hrs prior was 5.4mg/dL. Mild neonatal transaminitis was noted day of life 1; it normalized day 3.
To our knowledge, no case reports detail anesthetic management after overdose of both acetaminophen and ASA. Multiple reports of acetaminophen overdose detail FHR decelerations with no resultant neonatal compromise after delivery.1-2 A review of the literature found benefit to early administration of N-acetylcysteine.3 Reports of ASA overdose range from fetal demise after chronic and high dose ingestion to a large survey showing no fetal pathology.4-5
In this case, fetal acetaminophen effects were mild, likely due to early administration of N-acetylcysteine. However, fetal ASA effects were significant. Fetal elimination of ASA is slow due to immature renal function. ASA freely crosses the placenta and preferentially localizes to the fetal brain due to differences in the fetal blood brain barrier; this can lead to intracranial hemorrhage.6-7
Regarding anesthetic management, it is difficult to determine the bleeding risk for neuraxial anesthesia in the setting of multiple anticoagulants. The decision to perform spinal anesthesia was determined by a reassuring maternal laboratory and clinical status, although studies have shown an inconsistent effect of therapeutic doses of acetaminophen and ASA on ROTEM.8-9 Though this patient’s delivery was uncomplicated, there is a paucity of reports detailing the management of the parturient and safety of neuraxial anesthesia in the setting of concomitant toxic ingestions. Further reports may help elucidate maternal and fetal effects of large overdoses.
1.Taney Obstet Gynecol 2017
2.Mills Int J Obstet Anesth 2014
3.Wilkes South Med J 2005
4.Farid NDT Plus 2011
5.Flint Acta Obstet et Gynecol Scandan 2002
6.Garrettson Clin Pharmacol Ther 1975
7.Sassidharan Ind J Pediatr 2001
8.Marini Blood Coagul Fibrinoly 2014
9.Scharbert Platelets 2009