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Unusual Discrepancy in Maternal and Fetal Response to Ephedrine for Treatment of Maternal Hypotension During Neuraxial Labor Analgesia
Abstract Number: S1D-1
Abstract Type: Case Report/Case Series
We present here the case of a relative maternal insensitivity to ephedrine and an apparent discrepant fetal response resulting in prolonged fetal tachycardia, which almost caused an urgent cesarean delivery (CD).
A healthy 39 yo G3P2 received neuraxial analgesia prior to induction of labor (IOL) in the context of fetal transposition of the great arteries. Baseline maternal BP was 118/75mmHg and HR 94bpm. CSE analgesia (spinal bupivacaine 0.25% 1mL + fentanyl 10mcg) was placed uneventfully followed with low dose PCEA.
Shortly after, intracervical Foley balloon placement caused sudden blood loss of 200mL, with reported dizziness, nausea, systolic BP 53mmHg, HR 45bpm, and prolonged fetal deceleration (Figure). Fluid resuscitation and IV ephedrine (5mg repeated bolus) was initiated with no maternal response, resulting in a total cumulative dose of 50mg given over 10 minutes, with BP 115/56mmHg and HR 49bpm, and fetal tachycardia.
Due to persistent fetal tachycardia (180-190bpm for 50 min), a CD was decided for concern of fetal well-being in the setting of anomalous cardiac anatomy. Patient was brought to OR and epidural anesthesia achieved (20ml incremental 2% lidocaine); fetal heart tracing normalized (150bpm) while preparing for CD. Diagnosis of excessive fetal response to ephedrine was proposed and CD cancelled. IOL was resumed, and an uncomplicated vaginal delivery ultimately occurred 16 hours after CSE placement. Maternal and neonatal DNA were collected for exome sequencing.
Ephedrine is a vasopressor commonly used to treat intrapartum maternal hypotension, however it is associated with increased transplacental transfer and neonatal acidemia compared to phenylephrine1. Maternal ADRB2 genotype has been shown to influence ephedrine requirements for treatment of hypotension during CD2 and fetal ADRB2 genotype influences ephedrine-induced neonatal acidemia in exposed fetuses3. We suspect that 'discordant' maternal/fetal ADRB2 genotypes may explain the clinical scenario and extreme phenotypes observed here in response to intrapartum ephedrine. Exome sequencing results for both mother and baby will be presented SOAP meeting.
Vasopressor treatment for maternal hypotension may have differential effects on mother and fetus with significant repercussions at the time of delivery when genotypes/phenotypes are discordant.
1 Anesthesiol 2009;111:506-12
2 Anesthesiol 2006;104:644-50
3 Anesth Analg 2011;112:1432-8