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Journal of Obstrectic Anaesthesia and Critical Care
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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 44-46

Uterine hypertonia and nuchal cord causing severe fetal bradycardia in a parturient receiving combined spinal-epidural analgesia during labor: Case report and review of literature


1 Department of Anaesthesia and Critical Care, S N Medical College, Agra, Uttar Pradesh, India
2 Department of Obstetrics and Gynaecology, S N Medical College, Agra, Uttar Pradesh, India

Date of Web Publication4-Aug-2012

Correspondence Address:
Uma Srivastava
Department of Anaesthesia and Critical Care, S N Medical College, Agra, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.99324

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  Abstract 

Fetal bradycardia is common following spinal opioids administered for pain relief during labor. This slowing is usually benign and short lived. Although it leads to some anxiety among obstetricians and anesthesiologists, it rarely results in urgent operative delivery. Here, we are reporting a case where urgent caesarean delivery was needed due to severe and persistent fetal bradycardia following low-dose intrathecal fentanyl. Fetal bradycardia possibly was due to hypertonic uterine contractions complicated by tightly wrapped cord round the neck.

Keywords: Fetal bradycardia, intrathecal fentanyl, nuchal cord, uterine hypertonia


How to cite this article:
Srivastava U, Joshi K, Gupta A, Dwivedi Y, Singh S. Uterine hypertonia and nuchal cord causing severe fetal bradycardia in a parturient receiving combined spinal-epidural analgesia during labor: Case report and review of literature. J Obstet Anaesth Crit Care 2012;2:44-6

How to cite this URL:
Srivastava U, Joshi K, Gupta A, Dwivedi Y, Singh S. Uterine hypertonia and nuchal cord causing severe fetal bradycardia in a parturient receiving combined spinal-epidural analgesia during labor: Case report and review of literature. J Obstet Anaesth Crit Care [serial online] 2012 [cited 2019 Dec 11];2:44-6. Available from: http://www.joacc.com/text.asp?2012/2/1/44/99324


  Introduction Top


Fetal bradycardia is common following spinal opioids administered for pain relief during labor. This slowing is usually benign and short lived. Although it leads to some anxiety among obstetricians and anesthesiologists, it rarely results in urgent operative delivery. Here, we are reporting a case where urgent caesarean delivery was needed due to severe and persistent fetal bradycardia following low-dose intrathecal fentanyl. Fetal bradycardia possibly was due to hypertonic uterine contractions complicated by tightly wrapped cord round the neck.


  Case Report Top


A 27-year-old primigravida presenting at 37 weeks of pregnancy with labor pains requested regional analgesia for pain relief. She had single live fetus with cephalic presentation. The fetal heart rate (FHR) was 136 beats per minute (bpm) regular. She had not received any analgesic during preceding 12 hours and her verbal rating pain score was 7 on a scale of 0 - 10 (0 = no pain and 10 = worst pain imaginable). Following thorough clinical evaluation, informed written consent and hydration with 500 ml of ringer lactate solution, combined spinal epidural analgesia (CSEA), was performed in sitting position using double space technique. Epidural space was localized at L1-2 inter space with 18 G Tuohy needle using loss of resistance to air technique. After fixation of epidural catheter, spinal block was performed by 25 G Quincke needle at L3-4 inter space and 2 ml of solution containing 2.5 mg of bupivacaine and 25 μg of fentanyl was injected after obtaining free flow of CSF. No drug was given epidurally. The patient was immediately turned supine with pillow under the right hip. SpO2 and heart rate were monitored continuously and BP was measured non-invasively at 5-minute interval. FHR was monitored continuously for 15 minutes prior to block and continued post-block using external cardiotocograph along with auscultation by the attending obstetrician every 15 minutes. Uterine activity was monitored electronically as well as manually.

The patient became comfortable about 7 to 8 minutes after the block with pain score of one. After about 10 minutes, the patient had 3-4 rapid contractions in quick succession with incomplete relaxation between the contractions. There was a concomitant fetal bradycardia to 95 bpm with loss of beat to beat variation along with late deceleration for 2 to 3 minutes and then FHR returned to normal. The BP was stable, but the patient was placed in lateral position, O 2 by mask and IV fluids were given. A possible plan for emergency caesarean was made. Subsequently, the patient had a prolonged uterine contraction and uterus became hard and fetal parts could not be palpated. Meanwhile, the FHR dropped to 85 bpm. IV fluids and O 2 inhalation were continued and 100 μg nitroglycerine was given IV and FHR returned to 120 bpm within 3 to 4 minutes. Contraction recurred after 15 minutes and FHR dropped, ranging between 80 and 84 bpm. Second dose of NTG was repeated but FHR did not improve. Immediate caesarean section under epidural anesthesia was planned. The highest sensory dermatome level after initial intrathecal analgesia was T8 which had regressed to T10 level when surgery was planned. 18 ml of 1.5% lignocaine with 1 meq/10 ml of sodabicarbonate was administered in 5 ml incremental boluses till T4 sensory level was achieved. Surgical duration of 30 minutes was uneventful. In the intraoperative period, patient remained hemodynamically stable. When the baby was delivered, the cord was found to be tightly entangled twice round the neck. The cord was loosened and handed over to the neonatologist. Baby had an APGAR score of 4 at 1 minute but improved to 8 after resuscitation.


  Discussion Top


Fetal bradycardia after regional analgesia usually occurs within 30 minutes post block, is typically transient, lasts for 5 to 8 minutes, and then resolves spontaneously with simple measures involving position change, O 2 inhalation, hydration, vasopressors, suspension of oxytocin and tocolytic agents. [1],[2] The exact cause of fetal bradycardia after neuraxial analgesia is not clearly understood. Maternal hypotension, [3] uterine hyperactivity following higher doses of intrathecal opioids, [4],[5],[6] or concomitant use of oxytocin [7] may be probable causes. There is strong correlation between fetal bradycardia after labor analgesia induction and uterine hyperactivity but if uterus is quickly relaxed and fetus is properly resuscitated, outcome of delivery or neonatal health is not affected. [1],[2],[6],[8] Though the etiology remains elusive, it has been proposed that it may be related to acute reduction of circulating maternal catecholamine levels due to rapid pain relief. In addition, it has been postulated that an imbalance between epinephrine/ norepinephrine levels causes unopposed a adrenoceptors effect on uterine tone and decreases uterine blood flow. The reduction in uterine blood flow can reduce fetal oxygenation and cause fetal bradycardia. [4],[6],[9]

FHR abnormalities occur commonly during labor and have been reported following any type of effective analgesia. [10],[11] Few authors claim that they are commoner following intrathecal opioids than after conventional epidural analgesia, [4],[5] while others deny this. [12],[13] However, several recent studies and meta-analysis showed that despite occurrence of worrisome FHR abnormalities, urgent operative delivery for fetal distress is rarely required. [5],[6],[9],[14],[15] Furthermore, it has been suggested that certain factors unrelated to neuraxial analgesia could play a role in occurrence of FHR abnormalities. These include parturients with severe pain before block, [1],[13],[16] higher maternal age, [16] and when head is not engaged or when deceleration was present prior to initiation of analgesia. [17],[18] Uteroplacental blood flow pathology may also cause FHR changes and that a bias may be created by giving CSE to these women. [19] Two large studies demonstrated that emergency caesarean delivery for fetal distress within 90 minutes of CSEA occurred only in association with confounding obstetrical factor [17],[20] and CSEA may be just an innocent bystander. [21]

Among the common causes as cited above, (hypotension, use of high-dose opioids or oxytocin, uterine hypertonia) the most probable cause of fetal bradycardia in our patient was hypertonic uterine contractions. The diagnosis was suspected by the obstetric team on the basis of sustained uterine contractions as suggested by tocodynamometric tracings and manual abdominal palpation. It responded to intravenous nitroglycerine. As the parturient did not have any episode of hypotension and had not received oxytocin or high-dose opioids, these possibilities were unlikely. Also, the episode of uterine hyperactivity had responded to intravenous nitroglycerine. So, it was presumed by the attending obstetrician that the second episode of bradycardia could be due to tightly wrapped cord round the neck (nuchal cord). Cord around the neck has been often cited as a major obstetrical cause of acute fetal distress requiring urgent delivery. [17] Our case report supports the view of Clarke et al. [4] that acute pain relief may cause uterine hyperactivity which can be treated by tocolytic agents. This was evidenced by reduction of pain scores from seven to one within minutes of subarachnoid injection and subsequent hypertonic uterine contractions responding to intravenous nitroglycerine.

CSEA is an effective modality for pain relief during labor and except for few case reports of emergency caesarean delivery for fetal jeopardy, [4],[7] the technique with small dose of fentanyl is safe. Safety steps must be employed in selection of patients such as avoiding the technique in parturients with long cord or true knots. It is evident from this report that uterine hypertonic contractions and consequent fetal bradycardia could result due to quick pain relief. However, other causes such as nuchal cord should also be suspected if bradycardia persists as in our case.

 
  References Top

1.Riley ET. Labor analgesia and fetal bradycardia. Can J Anaesth 2003;50:R1-3.  Back to cited text no. 1
    
2.Van de Velde M. Neuraxial analgesia and fetal bradycardia. Curr Opin Anaesthesiol 2005;18:253-6.  Back to cited text no. 2
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3.D'Angelo R, Eisenach JC. Severe maternal hypotension and fetal bradycardia after combined spinal-epidural anaesthetic. Anesthesiology 1997;87:166-8.  Back to cited text no. 3
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4.Clarke VT, Smiley RM, Finster M. Uterine hyperactivity after intrathecal injection of fentanyl for analgesia during labor: A cause of fetal bradycardia? Anesthesiology 1994;81:1083-6.  Back to cited text no. 4
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5.Mardirosof C, Dumont L, Boulvain M, Tramer MR. Fetal bradycardia due to intrathecal opioids for labor analgesia: A systematic review. Br J Obstet Gynaecol 2002;109:274-81.  Back to cited text no. 5
    
6.Van de Velde M, Teunkens A, Hanssens M, Vandermeersch E, Verhaeghe J. Intrathecal sufentanil and fetal heart rate abnormalities:A double-blind double placebo-controlled trial comparing two forms of combined spinal - epidural analgesia with epidural analgesia in labor. Anesth Analg 2004;98:1153-9.  Back to cited text no. 6
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7.Friedlander JD, Fox HE, Cain CF, Dominguez CL, Smiley RH. Uterine hyperactivity following subarachnoid administration of fentanyl during labor. Reg Anesth Pain Med 1997;22:378-81.  Back to cited text no. 7
    
8.Palmer CM, Maciulla JE, Cook RC, Nogatni WM, Cossler K, Alves D. The incidence of fetal heart rate changes after intrathecal fentanyl labor analgesia. Anesth Analg 1999;88:577-81.  Back to cited text no. 8
    
9.Wong CA, Scavone BM, Peaceman AM, Mc Carthy RJ, Sullivan JT, Diaz NT, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med 2005;352:655-65.  Back to cited text no. 9
    
10.Norris Mc. Intrathecal opioids and fetal bradycardia: Is there a link? Int J Obstet Anesth 2000;9:264-9.  Back to cited text no. 10
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11.Van de Velde M. Modern neuraxial labor analgesia: Options for initiation, maintenance and drug selection. Period Biol 2009;111:171-85.  Back to cited text no. 11
    
12.Nielsen PE, Erickson JR, Abouleish EL, Perriatt S, Sheppard C. Fetal heart rate changes after intrathecal sufentanil or epidural bupivacaine for labor: Incidence and clinical significance. Anesth Analg 1996;83:742-6.  Back to cited text no. 12
    
13.Eberle RL, Norris MC, Mallozzi Eberle A, Naulty JS, Arkoosh VA. The effect of maternal position on fetal heart rate during epidural or intrathecal labor analgesia. Am J Obstet Gynecol 1998;179:150-5.  Back to cited text no. 13
    
14.Rofaeel A, Lilker S, Fallah H, Goldszmidt E, Carvalho J. Intrathecal plain versus hyperbaric bupivacaine for labor analgesia: Efficacy and side effects. Can J Anaesth 2007;54:15-20.  Back to cited text no. 14
    
15.Abrao KC, Francisco RP, Miyadahira S, Cicarelli DD, Zugaib M. Elevation of uterine basal tone and fetal heart rate abnormalities after labor analgesia: A randomized controlled trial. Obstet Gynecol 2009;113:41-7.  Back to cited text no. 15
    
16.Nicolet J, Miller A, Kaufman I, Guertin J. Maternal factors implicated in fetal bradycardia after combined spinal-epidural analgesia for labor pain. Eur J Anaesthesiol 2008;25:721-5.  Back to cited text no. 16
    
17.Norris MC, Fogel ST, Conway-long C. Combined spinal-epidural versus epidural labor analgesia. Anesthesiology 2001;95:913-20.  Back to cited text no. 17
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18.Gaiser RR, Chugh M, Cheek TG, Gutsche BB. Predicting prolonged fetal heart deceleration following intrathecal fentanyl/bupivacaine. Int J Obstet Anesth 2005;14:298-311.  Back to cited text no. 18
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19.Rosen MA, Hughes SC, Levinson G. Regional anesthesia for labor and delivery in shneider and levinsons anaesthesia for obstetrics. In: Hughes SC, Levinson G, Rosen MA, editors. 4 th ed. Philadelphia: Lippincott Williams and Wilkins; 2001. p. 123-48.  Back to cited text no. 19
    
20.Albright GA, Forster RM. Does combined spinal epidural analgesia with subarachnoid sufentanil increase the incidence of emergency cesarean delivery? Reg Anesth 1997;22:400-5.  Back to cited text no. 20
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21.Holdcroft A, Dob D. Regional analgesia for labor and fetal distress: Culprit or innocent bystander? Int J Obstet Anesth 2003;12:153-5.  Back to cited text no. 21
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