Epidural blockade in the treatment of preterm labour

Abstract

A case of' premature labour induced by necrosis in a jbromjwma followed by laparotomy is described. Unsuccessful treatment with ritodrine was ,followed by successful treatment with epidural analgesia The possible role of' a sjwipathetic blockade i . 7 discussed Key wordsAnuesthesia; obstctric. Anarsthetir. techniques, regional; epidural.Intra-abdominal conditions that necessitate operation during prcgnancy are often complicated by fetal death or prcmature labour. * -4 The most widely used treatment to prcvcnt preterm delivery consists of bed rest, sedatives and possibly a [I-sympathomimetic drug such as r i t~d r i n e .~.~ In some cases this treatment has been unsuccessful. USC of epidural blockade for the treatment of threatcncd prctcrm labour or abortion does not seem to have been rcportcd previously. Case historyA prcviously healthy 26-year-old woman who was in the 18th week of a twin pregnancy, was admitted to hospital with intermittent pain in the lower abdomen. Utcrinc contractions could be felt at intervals of 3-5 minutes. A tender swelling was present on the right side of the uterus. There was no dilatation of the cervix. Ultrasonography of the abdomen showed two live fetuses and a tumour that measured 8 x 8 cm located in the anterior wall of the uterus. The patient was treated with bed rest, diazepam and pethidinc. Thc frequency and intensity of the contractions, as well as thc pain, increased during the first 24 hours of admission and the treatment was therefore supplemented with intravcnous ritodrine.The contractions continued during the following 2 weeks despite the administration of ritodrine at dose levels up to 125 ,ug/minute. Higher doses resulted in unacceptable tachycardia, with a pulse rate of more than 120 beats/ minute and tremor. An attempt was made on several occasions to reduce the dosage of ritodrine but resulted in an increase in the intensity and frequency of the uterine contractions. Nccrosis in a fibromyoma, leading to premature contractions, was suspected as the size and tendcrncss of the turnour increased.A laparotomy was carried o u t on the 15th day. Light general anacsthesia was supplementcd with epidural analgesia with bupivacaine 0.5% via an epidural catheter inserted into the L2-3 interspace. The operation revealed a fibromyoma with a diameter of 8 cm, situated mainly within the uterine wall. Enucleation was therefore impossible.Treatment with ritodrine I00 pg/minute was continued for thc following 48 hours and the epidural blockade was maintained by repeated injections of bupivacaine 0.5%, 1 0 ml every 2 hours: this led to a level of analgesia around L,-z. The patient still complained of severe pain and the contractions were accompanied by effacement and dilatation of the cervix. Treatment with ritodrine was discontinued at this timc and a continuous infusion of lignocaine 1.0% with adrenaline 5 pgiml, 20 ml/hour, commenced via the epidural catheter. This led to a level of analgesia around T8-g. The contractions ceased within I ? hours of the start of this treatment but ...