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Epidural fo IUFD?

Discussion in 'Anesthesiology' started by cchoukal, Jun 1, 2008.

  1. cchoukal

    cchoukal Senior Member Moderator 10+ Year Member

    Jul 10, 2001
    SF, CA
    At my program, there's recently been some conflict between the OBs and us regarding pain management for patients with intrauterine fetal demise. Their opinion is that the patient is in pain form contractions/cervical dilation/etc. and that an epidural is indicated, as in any laboring woman. We have a number of attendings with differing opinions on this, but our section chief feels that:

    1) the indication for an invasive procedure (epidural) in a laboring patient is to protect the fetus from systemic analgesics (opiates), and this indication is absent in the IUFD patient.

    2) Discomfort in these patients can be effectively managed with opiates and sedatives.

    3) The risks and side effects of the epidural outweigh the benefits in these patients, and in addition, patients with IUFD are at increased risk for coagulopathy from DIC.

    Chestnut is quiet on the subject.

    What are people doing at other academic programs? What about out in PP?
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  3. jwk

    jwk CAA, ASA-PAC Contributor 10+ Year Member

    Apr 30, 2004
    Atlanta, GA
    Labor is labor, whether for delivery or IUFD. Give them the damn epidural if the patient wants one.
  4. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Nov 2, 2006
    The South
    Your chief's opinion does not make any sense!
    1- The indication for labor epidural is to protect the mother from a very bad thing called pain!
    2- There is no way opiates can be as good as epidurals at controlling any pain, if that was the case we wouldn't be doing epidurals on any surgery.
    3- If they have DIC don't give them an epidural.
    4- These patients are usually devastated and deserve all the support we can offer them, denying them an epidural for some stupid theoretical assumptions is simply inhumane.
  5. cchoukal

    cchoukal Senior Member Moderator 10+ Year Member

    Jul 10, 2001
    SF, CA
    Right, but the reason epidurals became popular for LABOR is because of the improved side effect profile for the fetus compared to IV opiates. Without a fetus, aren't opiates safer?
  6. dr doze

    dr doze To be able to forget means to sanity Lifetime Donor Classifieds Approved 10+ Year Member

    Dec 6, 2006
    Last edited: Mar 10, 2009
  7. Arch Guillotti

    Arch Guillotti Senior Member Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Aug 8, 2001
    We will usually put them in if requested so long as there are no contraindications.
  8. jetproppilot

    jetproppilot Turboprop Driver 10+ Year Member

    Mar 12, 2005
    level at FL210

    Tell your section chief I'm gonna attempt to take a billiard ball (ummm......5 stripe) and place it in his bladder.....


    He can have whatever opiod dose he picked for the unfortunate women under his care, or I'll put an epidural in him.

    Ask him.


    Like JWK said, labor is labor.

    man some of these academic guys amaze me with their obstructionalism!

    WHAT A BUNCHA CRAP......their pain can be managed with opiods...

  9. Gas

    Gas Member 10+ Year Member

    Nov 11, 2002
    Jet, do you check coags for these IUFD patients? We routinely check platelets for all patients, but I think coags for these people may not be a bad idea.
  10. jetproppilot

    jetproppilot Turboprop Driver 10+ Year Member

    Mar 12, 2005
    level at FL210
    We do not normally.

    Most of these women present like everyone else (as you know).

    Nothing physiologically sinister occurring.

    Except their baby is dead. :(
  11. cchoukal

    cchoukal Senior Member Moderator 10+ Year Member

    Jul 10, 2001
    SF, CA
    for what it's worth, my section chief has been doing OB his whole career, including a decade at one of the busiest Labor units in the country, and a stint in a busy PP as well. Not that I'm defending his opinion; I really just did want to know what others are doing. With regard to the labor aspect, does it matter if the fetus died at 20 weeks vs 35?

    And is there really nothing sinister occuring? I mean, isn't the idea that the dead baby releases all sorts of things into maternal circulation (that is, the underlying mechanism of the DIC)? I read a little about this, however, and Chestnut writes that DIC doesn't set in until 3-5 wks after demise (if delivery has not occurred by then). Seems like a pretty wide window before coagulopathy would set in.
  12. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Nov 2, 2006
    The South
    I actually think these women deserve an epidural and a painless delivery more than anyone else.
    Isn't it terrible enough that the poor woman just lost her baby and on top of that she has to sit there and go through hours of labor to deliver her dead child?
    DIC because of fetal demise is possible but rare and if you think that the fetus has been dead for a while it's not unreasonable to check coags, but denying these women epidural analgesia if there is no real contraindication is unacceptable and should be considered malpractice.
  13. pd4emergence

    pd4emergence Man or Muppet? 7+ Year Member

    Jun 10, 2007
    The question is what would you want for your wife? We don't put epidurals in just for the baby, we do it for the mom too. Narcotics just don't work as well for labor pain no matter what dose you give. I don't routinely check coags. Chestnut was the chair at my program, we did CLE's for these patients all the time.

  14. jetproppilot

    jetproppilot Turboprop Driver 10+ Year Member

    Mar 12, 2005
    level at FL210
    Its impossible for me to fathom why the dude would maintain an obstructionalistic attitude toward a patient population Plank described so eloquently above.

    Many academic decisions concerning anesthetic-clinical-care are made citing data about how a pathphysiologic process evolves.......without considering whether an action....or an inaction...contributes to


    Thats what we're concerned about, right?


    You read in some of our long-winded textbooks about something......ohhhhh....lets talk about the physiologic changes of pregnancy.

    Academic types are taught this, re-read it, then are scared s hitless to put a parturient to sleep for a C section, even if the situation dictates its the only choice (insert your scenerio here).....THEN they pass this mantra onto the residents who emerge into private practice with less-than-desired confidence/skill at applying skill/knowledge to this not-uncommon scenerio.

    Same with IUFD and regional anesthesia.

    You're a doctor.

    As soon as you walk in the room of this very unfortunate woman, your clinical prowess is gonna tell you whether or not her body is being ravaged by the dead fetus.

    If she's hypotensive, HR 150, tachypneic yeah, I'm gonna hesitate.

    But most of'em arent like that, and you shouldnt deprive an entire population of regional anesthesia during delivery based on a rare presentation.

    They, other than the very rare parturient, present like your pregnant wife/girlfriend/sister/friend.....except their baby is dead.

    Absolutely no reason, like Plank said, to put them thru the pain of their lives to deliver a dead baby, especially since there are no OUTCOME studies citing increased risk of morbidity/mortality resulting from parturient regional anesthesia during delivery of IUFD.

    Time to STEP UP TO THE MIKE WITH MICATIN and recognize that your section chief is perpetuating what I'm fighting against:


    Yes, you need to be aware of the zebras, and act accordingly when they present.

    But you shouldnt be taught to mould your practice based on theory and zebras.
    Last edited: Jun 1, 2008
  15. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

    Jun 20, 2005
    We place the epidurals for these pts as well. DIC is possible but rare and if it makes you feel better then check coags. But the vast majority of these pts come in within 2 weeks of fetal death and the DIC issue is just not an issue at this time.

    Now with twins were one of the twins has died and the other is survivable the stakes change. These cases get my attention.
  16. MTGas2B

    MTGas2B Cloudy and 50 Physician Faculty 10+ Year Member

    Sep 22, 2004
    In my academic institution we offer these patients epidurals and/or PCAs. Somtimes they want to give it go with a PCA, a few change their mind. We're happy to change plans.

    When it comes to coags in your OB patients do you guys check TEGs at all?
  17. jwk

    jwk CAA, ASA-PAC Contributor 10+ Year Member

    Apr 30, 2004
    Atlanta, GA
    Does anyone outside of residency use TEGS for anything, ever, except perhaps for hearts or vascular?
  18. Arch Guillotti

    Arch Guillotti Senior Member Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Aug 8, 2001
    I would not know what to do w/ a TEG if I saw one.
  19. amyl

    amyl ASA Member 10+ Year Member

    whats TEGS?
  20. Gern Blansten

    Gern Blansten Account on Hold 10+ Year Member

    Jun 20, 2006
  21. Leinie

    Leinie ASA Member 10+ Year Member

    Jun 20, 2004
    I do CT anesthesia exclusively in PP and haven't looked at a TEG since I left fellowship. And we bring a lot fewer patients back for bleeding.
  22. Laurel123

    Laurel123 Member 7+ Year Member

    Jul 20, 2005
    While your chief makes good points, I think we as doctors need to evaulate each patient and not just put a blanket assumption over all of them. Yes, IUFD can cause DIC. But it is very rare and these patients are usually quite sick.

    Also, it seems that some people have confused a sad, grieving patient with an incompetent patient. Patients with an IUFD may be very upset or distressed, but they can still give informed consent. So if after evaluating a patient, there is no reason to not give her the option of an epidural vs. PCA with informed consent.
  23. urge

    urge 10+ Year Member

    Jun 23, 2007
    Posted via Mobile Device I vote for epidermal.
  24. dillpickles

    dillpickles 7+ Year Member

    Jan 7, 2008
    At my institution epidurals are routinely put in for IUFD if mom wants it, after checking her coags. I agree with pd4emergence, what someone want done for their wife or sister?
  25. CerebralEdema

    CerebralEdema Anesthesia/Pain MD 7+ Year Member

    May 14, 2008
    We too here place epidurals for all IUFD pts that request our asssitance. We do not routinely check Coags, but we usually get a cbc w/ platelets. Of course if the pt looks toxic then get a DIC panel, but otherwise just treat her pain the BEST way that you can... in this instance its hand-down no-questions-asked EPIDRUAL all the way.

    It makes me laugh-out-loud that OPIOIDS are as good as relieving labor pain as an epidoodle. What foolishness.
  26. mgrdoc


    Sep 18, 2008
    As a doctor and a woman that just had a IUFD, if there are not contraindications, just give the damn epidural. The grief is enough to handle let alone having to deal with any physical pain. Knowing that you have to deliver your dead baby is hard enough without the pain of labor to add to the mix.
  27. isoman2000

    isoman2000 Banned

    Jul 10, 2008
    Epidural yes.
  28. drccw

    drccw ASA Member 7+ Year Member

    Jan 20, 2008
    I give patients with IUFD pretty much whatever they want.. it's a crummy time for them and in my mind they get whatever support they want or desire. I tell them that the full range of my services are available.. if the OBs are squeamish with the benzodiazepine orders, I write. I'm of course not going to do anything unsafe or crazy but I will be aggressive in anxiolysis and analgesia...
  29. pushthesux

    pushthesux Junior Member Physician 10+ Year Member

    Oct 24, 2005
  30. SleepIsGood

    SleepIsGood Support the ASA ! 5+ Year Member

    Apr 15, 2006
    Hey man...

    great post. very interesting points that your chief brought up. I think his concern his valid. I just dont know the CLINICAL significance. I have never had a pt with IUFD. Atleast now, I would consider obtaining coags definitely.
  31. CanGas

    CanGas Member 5+ Year Member

    Feb 1, 2006
    I vote epidural. Check labs if available but if afebrile, hemodynamically stable and no other disease process (pre-eclampsia, abruption, rupture) I would just proceed.


    Quick google search pulls up references below:
    FAQ 12: Neuraxial Analgesia in the Parturient with Fetal Demise

    Does SOAP have recommendations for labor epidural placement in parturients with an intrauterine fetal demise?

    SOAP does not have specific guidelines. Please refer to the following reference: Maslow AD, Breen TW, et. al. Prevalence of coagulation abnormalities associated with intrauterine fetal death. Can J Anaesth. 1996; 43:1237-43.

    Additional information about platelet counts can be found in the ASA Practice Guidelines for Obstetric Anesthesia:

    Prevalence of coagulation abnormalities associated with intrauterine fetal death
    AD Maslow, TW Breen, MC Sarna, AK Soni, J Watkins and NE Oriol
    Department of Anesthesia and Critical Care, Beth Israel Hospital, Harvard Medical School, Boston, MA 02215, USA.

    PURPOSE: The purpose of this study was to determine factors associated with abnormal coagulation in the setting of intrauterine fetal death (IUFD). METHODS: We reviewed the charts of 238 patients diagnosed with IUFD over ten years. Data included demographics, co-existing obstetric disease and coagulation studies. A coagulation score was assigned based on the platelet count, prothrombin time, activated partial thromboplastin time and plasma fibrinogen concentration. Approximately 90% of the study population had coagulation scores < 4. A score of > or = 4 was considered abnormal. RESULTS: Complete coagulation analysis was available in 183/238 patients (77%) within 24 hr of delivery. One hundred and sixty-four of these (89.6%) had a coagulation score, < 4 and 19 had a score > or = 4 (10.4%). No relationship between the coagulation score and age, parity, gestational age at delivery, and number of days the dead fetus remained in utero was found. A coagulation score > = or 4 was associated with the presence of a pregnancy-related disease (P < 0.05), notably abruption (P < 0.001) and uterine perforation (P < 0.05). Four patients without co-existing disease (3.2%), had a coagulation score > or = 4. CONCLUSION: In most pregnancies complicated by fetal demise, the fetus and placenta are delivered within one week of fetal demise. The previously reported severe coagulation disturbances are largely eliminated by early delivery. Our study shows that coagulation abnormalities occur in some patients with uncomplicated IUFDs (3.2%) and that this number rises in the presence of abruption or uterine perforation.

    Influence of Epidural Anaesthesia on the Course of Labour in Patients with Antepartum Fetal Death
    Samuel Lurie MD* , 1 , Isaac Blickstein MD*, Michael Feinstein MD*, Avi Matzkel MD*, Tiberiu Ezri MD† David Soroker MD†
    *Departments of Obstetrics and Gynaecology, Kaplan Hospital, Rehovot, Israel (Affiliated to the Medical School of the Hebrew University and Hadassah, Jerusalem) †Departments of Anaesthesiology, Kaplan Hospital, Rehovot, Israel (Affiliated to the Medical School of the Hebrew University and Hadassah, Jerusalem)
    Correspondence to 1 Department Obstetrics and Gynecology, Kaplan Hospital, 76100 Rehovot, Israel.
    Copyright 1991 Royal Australian and New Zealand College of Obstetricians and Gynaecologists
    Summary: The course of labour in 22 patients with antepartum fetal death who received epidural anaesthesia was evaluated as compared to 22 controls matched for parity and gestational age, who received narcotic pain relief. Both groups had similar preinduction cervical dilatation and the induction was performed by amniotomy and oxytocin infusion. The mean first stage of labour was 5.4 hours in the epidural group, and 8.7 hours in the controls (p = 0.0192). The mean cervical dilatation rate was 3.3 cm/hour and 1.0 cm/hour respectively (p = 0.0142). The second stage was similar in both groups. We conclude, that parturients receiving epidural anaesthesia may benefit both emotionally and physically from excellent pain relief and a shorter delivery process when going through the distressing experience of delivering a dead fetus.
  32. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Nov 2, 2006
    The South
    I am sorry, but if someone says that labor pain can be effectively managed by IV narcotics, and uses this argument to deny a devastated woman who just lost a child epidural analgesia I would not consider that neither valid nor interesting.
    Last edited: Sep 19, 2008
  33. smq123

    smq123 John William Waterhouse Administrator Physician SDN Advisor 10+ Year Member

    Jan 9, 2006

    I know I'm just a med student, but from the OB perspective, your section chief's decision doesn't make any sense.

    DIC (if it occurs) tends to occur 4-5 weeks after the IUFD. Most IUFDs are delivered within 2 weeks of the demise. (This is according to Williams Obstetrics, anyway.) It doesn't seem like the worry about DIC should make people overly cautious about putting in epidurals.

    On my OB rotation, we saw a patient who was in a coma. While in the coma, she had an IUFD. The OBs didn't make a move to induce her or deliver her - in her case, the risk of uterine rupture with a D&C outweighed the risk of DIC.

    :( I'm so, so sorry. *hug*
  34. chicafro


    Nov 8, 2007
    like the others, our program does not hold back on epidurals for IUFD...the patient is given the option of opioids vs epidural and in my limited experience thus far it seems that most of them do end up going the epidural route.

    one of our OB anesthesiologists is pretty adamant about respecting the woman's right to be awake and alert (but not in pain!) after the delivery so that she can hold the baby, say goodbye and have some closure...not to sound too touchy-feely but it can be an important part of the grieving process. of course, other women would prefer to be snowed and not remember anything, and we can accomodate that as fact, it is pretty tough to control OB pain with opiods without them zonking out in the process.
  35. mgrdoc


    Sep 18, 2008
    It's the worst time ever in a woman's life. I agree that she should have a choice and am glad that most of you agree. It's heartbreaking (lost my little girl only 7 weeks ago) and it's important for the woman and whomever she choose to be able to hold their baby and do whatever they need to, to have some closure. It's a life changing event and I had wonderful docs and nurses. It's important to have compassion during this time and not feeling any pain is one thing that's extremely important. It's hard enough to deliver the baby. And like someone else said... what if this was your wife, your sister, your daughter!!!

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