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Management of a laboring patient with Addison's disease and antiphospholipid syndrome: a case report
Abstract Number: RF4AD-406
Abstract Type: Case Report Case Series
A 34 year-old G1P0 at 37w0d with a history of Type 1 diabetes, Addison’s disease, hypothyroidism due to papillary thyroid cancer s/p thyroidectomy, and antiphospholipid syndrome (complicated by pulmonary embolism), presented to labor and delivery for scheduled induction of labor (IOL).
Her prenatal course was complicated by hospital admission at 16 weeks gestational age (wga) for Addisonian crisis for which she received stress dose steroids and again at 35 wga for hyponatremia and emesis for which she repeated stress dose steroids and an increase of fludrocortisone. Therapeutic anticoagulation was maintained during pregnancy with enoxaparin and diabetes was controlled on insulin pump.
Labor was induced with cervical ripening balloon, misoprostol, and oxytocin. Addison’s disease was managed with stress-dosed hydrocortisone, fludrocortisone and fluid restriction for hyponatremia. She was transitioned to an insulin drip. Enoxaparin was stopped and prophylactic subcutaneous heparin started. Labs were notable for INR 0.9, PLT 322, HCT 32.9, Na+ 130. Early epidural was placed between doses of heparin. During second stage of labor she had 1 hour of passive descent followed by 2.5 hours of pushing, epidural was too dense and rate was decreased. Recurrent late decelerations of the fetus with prolonged time to recovery of baseline developed. Vacuum assisted delivery failed and she was taken emergently for cesarean section. Epidural was bolused with 2% lidocaine and 100mcg of fentanyl but failed to achieve surgical block, therefore general anesthesia was induced. After delivery she received methergine and tranexamic acid for an estimated blood loss of 1000mL. Oxytocin use was limited due to potential for worsening hyponatremia.
Postpartum she developed ileus and urinary retention thought to be related to recent surgery. Enoxaparin was restarted 6 hours after delivery for a course of 30mg Q6H for 36 hours then placed back on therapeutic dosing of 70mg BID with plan to follow up with hematology.
She was transitioned back onto insulin pump for which was complicated due to hypoglycemia. For Addison’s disease, stress dosed steroids were continued for 24 hours and then tapered.
Multispecialty coordination is important in patients with medical issues, this case involved endocrinology, hematology, obstetrics, and anesthesiology. The decision to place the epidural early was due to new ASRA guidelines suggesting a wait of 4-6 hours after heparin. The epidural was placed despite lack of labor pain due to need for continuing heparin prophylaxis in a high risk patient. Though the epidural worked well for labor, it was inadequate for surgery. She was not a candidate for a spinal due to recent dosing of subcutaneous heparin which lead to general anesthesia. General anesthesia, heparin and the need to limit oxytocin likely all contributed to the increased blood loss at delivery.