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Optimal pain management in a patient on suboxone after a planned repeat cesarean delivery turning into an unexpected cesarean/hysterectomy for morbidly adherent placenta (accreta)
Abstract Number: RF1BA-242
Abstract Type: Case Report Case Series
Despite an alarming increase in the number of pregnant women on methadone or buprenorphine, there are no specific recommendations guiding postpartum pain management, and balancing the risks of poorly managed pain and withdrawal with that of respiratory depression is challenging in opioid-tolerant women. We present the case of a woman with OUD requiring a cesarean hysterectomy (C/Hyst) in the setting of an unexpected placenta accreta.
A 39 yo G3P1 with OUD following a motor vehicle accident was scheduled for a repeat CD at 36 weeks in the setting of placenta previa; there was no evidence of parametrial invasion of the placenta on MRI. The patient was maintained on Suboxone 2mg daily throughout pregnancy. During pre-anesthesia consult, she appeared depressed and anxious, and expressed the desire to avoid systemic opioids after CD. She agreed with plan for a CSE for CD and opioid-sparing multimodal analgesia with prolonged epidural analgesia (48-72h). After delivery (3195g baby girl; APGAR 9/9), the placenta was found to be morbidly adherent and a hysterectomy was decided (under GA, with arterial line and additional peripheral access). Hemodynamic status was stable despite EBL of 2500ml (4 units of pRBCs & 2 units of FFP). The patient was extubated at the end of case and transferred to the high-risk unit. Post-operative pain management was carried as planned with prolonged epidural analgesia (see Table). The epidural catheter was removed on postpartum day 3. The patient did not take oral opioids and was discharged on postpartum day 4.
Reviewing the scarce available literature on post-cesarean pain management in women on Suboxone, there seems to be 2 opposing approaches with regards to using neuraxial fentanyl or morphine. In some reports, neuraxial opioids are omitted under the premise that the high binding affinity of buprenorphine will result in limited u-opioid receptor availability and neuraxial opioids will ‘not work’ and IV hydromorphone is proposed, others suggest maximizing neuraxial local anesthetics with opioids (possibly at even higher doses ± clonidine with appropriate monitoring) in combination with non-opioid adjuvants. Since our patient was highly motivated to avoid systemic opioids, repeated dosing of epidural morphine proved effective and the patient was very satisfied. To our knowledge this is the 1st report of an unexpected C/Hyst in the setting of Suboxone use.
1. Obstet Gynecol 2017;130:e81-94