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Expectant management of a parturient with serotonin syndrome
Abstract Number: RF7A10-59
Abstract Type: Case Report Case Series
Serotonin syndrome is an uncommon but potentially fatal condition caused by serotonin excess in the central nervous system.1 To our knowledge, there are no reports of serotonin syndrome in pregnancy.
A 36-year-old G3P1011 at 36w6d with a history of bipolar disorder type I, generalized anxiety disorder, postpartum depression, and substance abuse presented with intractable nausea, vomiting, diarrhea, tremor and hypertension. Psychiatric medications included lurasidone (increased dose one month prior), buspirone, and clonazepam. During a routine prenatal visit, the patient reported symptoms of hopelessness and fatigue for which she was prescribed sertraline. The following day, the patient developed intolerance of oral intake with worsening nausea, vomiting and diarrhea which continued over the next six days. During this time, she self-administered ondansetron and reported taking caffeine pills for increasing fatigue.
On initial presentation she was tremulous without muscle rigidity, BP 173/78, QT interval 490 ms, and labs were concerning for ketonuria, hypokalemia, metabolic acidosis, and a leukocytosis. Fetal heart rate (FHR) was 167 with a BPP of 6/8.
All serotonergic medications were held due to suspicion for serotonin syndrome. Her nausea and vomiting were treated with diphenhydramine and prochlorperazine, and she was rehydrated with 2.5 L lactated ringers followed by 4 L normal saline with 5% dextrose and electrolyte repletion. Her lab abnormalities normalizing by hospital day (HD) 3 and BPP improved to 8/8. However, she continued to have mild range blood pressures which met criteria for gestational hypertension. She subsequently underwent induction of labor on HD 4 and an L2/3 early labor epidural analgesic was placed. The catheter was loaded with 5 ml of bupivacaine 0.125% with a maintenance infusate of 0.1% bupivacaine. During labor the catheter was replaced with a combined spinal epidural (CSE) one level lower due to sacral sparing unresponsive to top-ups. CSE initiation was complicated by hypotension (79/46) responding to vasopressor administration and a fluid bolus. The epidural infusate was also changed to bupivacaine 0.083% with fentanyl 2 mcg/ml with the new epidural catheter. Her labor course was otherwise uncomplicated, and she delivered a healthy neonate at 37w3d on HD 4. The patient’s recovery was unremarkable, and she was discharged to home on HD 6, postpartum day 2.
The principles of managing serotonin syndrome in pregnancy focus on maternal optimization. In addition to discontinuation of offending agents and treatment of hemodynamic derangements, anesthetic planning should include avoidance of triggering agents. In general, delivery should be avoided pending resolution of serotonin syndrome. However, an early labor epidural analgesic without opioid should be considered in a parturient in labor with serotonin syndrome.
1. Saraghi M, et al. Anesth Prog 2018; 65: 60-65