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Continuous Epidural Hydromorphone Infusion for Post-Cesarean Delivery Analgesia in a Patient Maintained on Methadone
Abstract Number: RF1BA-276
Abstract Type: Case Report Case Series
A 30-year-old G2P0102 with PMH of obesity, chronic HTN and polysubstance abuse, maintained on daily methadone, presented for repeat cesarean delivery (CD) at 38w2d.
About 2.5 years prior, she underwent CD of di-di twins at 35w6d due to superimposed preeclampsia. Combined spinal-epidural (CSE) was performed at L4/5 with 0.5% bupivacaine 1.8mL, morphine 0.2mg, fentanyl 10mcg and epinephrine 200mcg (spinal), and incremental epidural dosing of 2% lidocaine + epinephrine 13mL during the procedure. Postoperative management included methadone 165mg daily, PO oxycodone as needed, IV ketorolac (0-24 hrs), PO ibuprofen (24 hrs until discharge) and PO acetaminophen as needed. Pain control was difficult, reflected by an average of oxycodone 85 mg/24h and average maximum daily pain scores of 8/10. Discharge occurred 3d 22h after delivery.
For her current CD, an L3/4 epidural was placed and incrementally dosed with 0.5% ropivacaine 25mL, morphine 2mg and fentanyl 85mcg. About 30 minutes after delivery, epidural hydromorphone was initiated at 140mcg/h with PCEA 20mcg, 30 minute lockout for a total dose of 3.36mg/24hrs. Postoperative management also included methadone 190mg daily, PO oxycodone as needed, IV ketorolac, PO ibuprofen and PO acetaminophen. Compared to her previous delivery, average 24h oxycodone use decreased to 2.5mg, pain scores improved to 4-5/10 daily, and she was able to ambulate. She was discharged 2d 4h after delivery. The epidural was removed 12 hours prior to discharge. Her overall satisfaction was much greater after her second CD.
Discussion: Since 1999, the prevalence of opioid use disorder (OUD) has quadrupled in pregnant women (1). Among recommended opioid agonist pharmacotherapies, buprenorphine results in lower incidences of fetal and neonatal morbidity, although pregnant women are still sometimes maintained on methadone (2).
Despite therapy, management of postpartum pain in women with OUD remains a formidable challenge for obstetric anesthesiologists. Meyer et al. found that after CD, 33 women on maintenance methadone therapy had higher pain scores and as much as a 70% increase in opiate use, averaging 91.6mg oxycodone/24hrs (3). Institutional data also reveals similar trends among 46 women, requiring 83.3mg oxycodone/24hrs.
Prior studies have compared single dose neuraxial hydromorphone to morphine in postpartum women without findings of statistical or clinical significance (4). Although continuous epidural hydromorphone has been used after thoracotomy (5), no studies explore its postpartum efficacy in opioid dependent or abusing women. We propose that utilization of continuous epidural hydromorphone may serve as a viable approach in women with OUD on methadone, evidenced by decreased pain scores and shorter hospital stay in this case report.
1. MMWR. 2018;67:845-849
2. Pharmacotherapy. 2017;37:824-839
3. Obstet Gynecol. 2007;110:261-266
4. Int J of Obstet Anesth. 2017;30:16-22
5. Ann Thorac Surg. 1990;50:888-93