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      Thoracic epidural analgesia to control malignant pain until viability in a pregnant patient

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          Abstract

          Management of nonobstetric pain in the pregnant patient presents unique challenges related to transplacental fetal exposure to opioids and the subsequent risk of neonatal withdrawal syndrome. We present the case of a pregnant patient suffering from the pain of a progressively enlarging thoracoabdominal sarcoma. Epidural analgesia (using local anesthetics with minimal opioid) was utilized over a span of weeks to manage oncologic pain, limiting fetal opioid exposure and culminating in the birth of a healthy infant. While nonobstetric abdominal pain during pregnancy is not that uncommon, neoplastic abdominal pain does appear to be rare. Combined local anesthetic and opioid continuous epidural infusion should be considered a viable option in the pain management approach to obstetric patients with nonobstetric pain associated with malignancy.

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          Most cited references 21

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          Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine.

           ,   (2010)
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            Premature foetal closure of the arterial duct: clinical presentations and outcome.

            The prevalence of intra-uterine ductal dysfunction is unknown and the clinical consequences are poorly understood. The aim of this study was to investigate the echocardiographic (ECHO) abnormalities and outcomes of this rare phenomenon. Retrospective analysis of foetal (n = 602) and neonatal ECHO databases (n = 1477) between 1998 and 2007. Clinical and imaging studies were reviewed for pathology due to or associated with premature closure of the duct. Twelve cases were identified. Eight (1.3%) were diagnosed pre-natally at a median gestational age of 29.0 weeks (range: 20.0-37.5 weeks). Four neonates (0.3%) with significant cyanosis and absence of the arterial duct were also included. The most common ECHO features were: excessive right ventricular (RV) hypertrophy (100%), more than expected tricuspid and pulmonary regurgitation (100% and 92%, respectively), and right atrial dilation (75%). Premature induction of delivery was advised for five patients. Neonatal therapy consisted of observation and oxygen administration (n = 7), ventilation with pulmonary vasodilators (n = 5), and one required extracorporeal membrane oxygenation. There were three deaths due to respiratory failure with severe pulmonary hypertension. During follow-up, two children required additional right heart procedures and one developed a non-compaction cardiomyopathy. Foetal premature closure of the arterial duct causes stress at different foetal ages and many different levels of the right heart and pulmonary circulation, resulting in a wide range of secondary pathology. Disproportionate RV hypertrophy is the most common finding. Clinical outcomes range from mild symptomatology to lethal respiratory insufficiency.
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              MR imaging evaluation of abdominal pain during pregnancy: appendicitis and other nonobstetric causes.

              Clinical diagnosis of the cause of abdominal pain in a pregnant patient is particularly difficult because of multiple confounding factors related to normal pregnancy. Magnetic resonance (MR) imaging is useful in evaluation of abdominal pain during pregnancy, as it offers the benefit of cross-sectional imaging without ionizing radiation or evidence of harmful effects to the fetus. MR imaging is often performed specifically for diagnosis of possible appendicitis, which is the most common illness necessitating emergency surgery in pregnant patients. However, it is important to look for pathologic processes outside the appendix that may be an alternative source of abdominal pain. Numerous entities other than appendicitis can cause abdominal pain during pregnancy, including processes of gastrointestinal, hepatobiliary, genitourinary, vascular, and gynecologic origin. MR imaging is useful in diagnosing the cause of abdominal pain in a pregnant patient because of its ability to safely demonstrate a wide range of pathologic conditions in the abdomen and pelvis beyond appendicitis.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2016
                13 June 2016
                : 9
                : 357-360
                Affiliations
                [1 ]Department of Anesthesiology, UT Health, McGovern Medical School, Houston, TX, USA
                [2 ]Orlando Health, Orlando, FL, USA
                [3 ]UT Health, McGovern Medical School, Houston, TX, USA
                Author notes
                Correspondence: Jaideep H Mehta, Department of Anesthesiology, UT Health, McGovern Medical School, 6431 Fannin Street, MSB 5.020, Houston, TX 77030, USA, Tel +1 713 500 6200, Fax +1 713 500 6201, Email Jaideep.H.Mehta@ 123456gmail.com
                Article
                jpr-9-357
                10.2147/JPR.S97155
                4912345
                27358573
                © 2016 Mehta et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Case Report

                Anesthesiology & Pain management

                sarcoma, malignant, pregnancy, epidural

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