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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Epidural Labor Analgesia in Parturient with Complex Regional Pain Syndrome and Preeclampsia: 24-hour Pain-Free Period during Postpartum Magnesium Infusion

Abstract Number: S5C-3
Abstract Type: Case Report/Case Series

Michael G Richardson MD1 ; Jonathan A Niconchuk MD2

Case

29 y/o G1 with discordant di-di twins presented at 35 4/7 weeks with BP 160/94, headache, blurred vision, and platelet count 94,000. She suffered chronic severe left foot and leg pain due to poorly controlled CRPS type 1 following trauma 10 years prior, for which a spinal cord stimulator (SCS) had been placed. Preeclampsia was diagnosed, IV magnesium (Mg++) therapy was initiated, and labor was induced. CT images confirmed SCS electrodes at T11-12 with leads traversing to left hip (figure).

She requested labor analgesia at 4cm cervical dilation. An epidural catheter was placed uneventfully at L3/L4 via right paramedian approach. It produced effective analgesia for labor and CRPS pain for 13 hours before an uneventful twin vaginal delivery. Mg++ seizure prophylaxis continued for 24 hours, during which she continued to experience complete relief of CRPS pain. Her CRPS pain returned promptly after Mg++ was discontinued. Prior to discharge, she made several inquiries about magnesium therapy for pain relief.

Discussion

Alleviation of CRPS pain was complete, and was initially presumed to be due to epidural analgesia. But, surprisingly, our patient remained pain-free for 24 hours after delivery, for the duration of the Mg++ infusion, which suggests a causal relationship. Glutamate and calcium influx play key roles in NMDA receptor activation, which is thought to be key in neuronal sensitization. Because Mg++, a physiologic calcium antagonist, down-regulates NMDA receptor activation, its therapeutic analgesic effects have been explored. Many preclinical and perioperative clinical trials of systemic and neuraxial Mg++ administration demonstrate analgesic effects.[1,2] In contrast, only two RCTs have studied systemic Mg++ in CRPS,[3,4] with only one demonstrating benefit compared to placebo.[4] The Mg++ administration dose for preeclampsia in our patient was much higher than those reported by these two trials, and may account for the profound analgesic effect she experienced. This report adds to the evolving evidence regarding magnesium’s role in pain and analgesia.

Separately, availability of radiologic images facilitated safe conduct of neuraxial block in presence of indwelling SCS, which will also be discussed.[5]

1. Bujalska-Zadrozny M et al. Eur J Pharmaceut Sci 2017;99:113

2. Srebro D et al. Curr Med Chem 2017;24:424

3. Fischer S et al. Pain Med 2013;14:1388

4. van der Plas A et al. J Pain 2013;14:1341

5. Young A et al. Reg Anesth Pain Med 2015;40:276



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