Treatment of breakthrough labor pain with epidural dexmedetomidine: a case series

Abstract

Breakthrough labor pain, defined as the return of pain despite ongoing administration of neuraxial analgesia, poses a significant challenge within the field of obstetric anesthesia. Epidural adjunct medications may be used to enhance neuraxial block density or provide coverage to previously spared regions. Dexmedetomidine, a US Food and Drug Administration–approved selective alpha-2 adrenergic agonist, has gained attention for an off-label use as a labor epidural adjunct medication for labor analgesia. This case series highlights three cases of epidural dexmedetomidine use for breakthrough pain during labor.

KEY POINTS

• Epidural dexmedetomidine may play a role in patients with an appropriate sensory block on exam but persistent breakthrough pain.

• Providers may consider epidural dexmedetomidine as an adjunct medication in unique situations when there is a technically difficult placement with resultant inadequate density or spared regions of the block, or in patients with a history of chronic pain.

CME

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CASE 1

A 32-year-old, gravidity (G) 5 parity (P) 0 at 35 weeks and 3 days gestation with a history of seizures, major depressive disorder, prediabetes, and class III obesity (body mass index [BMI] 50.9 kg/m²) presented to labor and delivery for induction of labor (IOL) following premature rupture of membranes. She opted for neuraxial analgesia. A challenging dural puncture epidural was performed, requiring three attempts. A dural puncture epidural was performed to help confirm placement location and provide faster analgesia onset. The epidural infusion consisted of ropivacaine 1 mg/mL–fentanyl 2 mcg/mL, utilizing programmed intermittent epidural bolus (PIEB) settings of 9 mL every 50 minutes. Nine hours later, the patient experienced breakthrough gluteal and vaginal pain. A 10 mL epidural bolus of 0.2% ropivacaine was administered, but pain persisted despite bilateral loss of cold sensation at the T7 dermatome level. Dexmedetomidine was added to her epidural infusion at a rate of 0.048 mcg/kg/h, which resulted in improved pain control. The infusion was decreased to 0.025 mcg/kg/h 4 hours later with adequate pain control. Twenty-nine hours after IOL, the patient underwent an uncomplicated intrapartum primary low transverse cesarean section for nonreassuring fetal heart tones and prolonged rupture of membranes. Her original labor epidural was dosed with lidocaine 2% with epinephrine 1:200,000 (20 mL), fentanyl (100 mcg), and dexmedetomidine (20 mcg) to provide surgical anesthesia (bilateral T4 level to pinprick). After surgery, the epidural was removed without complications. No adverse maternal hemodynamic effects were noted throughout labor, cesarean section, or in the immediate postoperative period from epidural dexmedetomidine administration. The patient was discharged on postoperative day 3.

CASE 2

A 23-year-old G2P1 at 34 weeks and 5 days gestation with a history of chronic hypertension, sickle cell disease complicated by avascular necrosis of the right hip and chronic kidney disease, chronic pain managed with hydrocodone/acetaminophen 10/325 mg every 6 hours, and BMI 31.9 kg/m² underwent IOL for severe preeclampsia. An uncomplicated single-attempt labor epidural was performed and initiated with ropivacaine-fentanyl PIEB settings. Eight hours after placement, she reported hip pain despite a bilateral T10 level to ice. Her epidural was bolused with dexmedetomidine (10 mcg), followed by the addition of epidural dexmedetomidine (0.048 mcg/kg/h). Adequate pain control was achieved. Twenty-six hours after IOL, the patient underwent an uncomplicated primary low transverse cesarean section for failure to progress using the same labor epidural. Surgical anesthesia was achieved with lidocaine 2% with epinephrine 1:200,000 (15 mL) and fentanyl (100 mcg) through the epidural. She was discharged on postoperative day 7.

CASE 3

A 23-year-old G1P0 at 38 weeks and 4 days gestation with no significant history and BMI 28.2 kg/m² presented in active labor. An uncomplicated single-attempt epidural was placed and analgesia was initiated using the same ropivacaine-fentanyl PIEB infusion as stated above. Three hours after epidural initiation, she reported a unilateral block with a right-sided T8 sensory level and no level on the left. The epidural catheter was withdrawn 1 cm and bolused with ropivacaine 0.1% (10 mL). No change in her sensory block prompted an uncomplicated epidural replacement. One hour later, she reported inconsistent dermatomal coverage, leading to a third uncomplicated epidural placement with appropriate labor analgesia established (bilateral T8). Four hours after the third epidural placement, she reported breakthrough hip pain and ropivacaine 0.2% (5 mL) was administered. Fifty minutes later, persistent suboptimal pain control prompted the addition of epidural dexmedetomidine at a rate of 0.009 mcg/kg/h. On reassessment, her pain was appropriately controlled (bilateral T10). No additional adjunct medications were required for her vaginal delivery. There was no evidence of maternal or fetal hemodynamic instability through her labor course. She was discharged on postpartum day 2.

Clinical questions

1. A 20-year-old laboring patient with a BMI of 50 kg/m² experienced a difficult three-attempt dural puncture epidural placement. Currently, she is experiencing breakthrough pain with contractions despite a bilateral T10 level to ice. Which of the following is the best next step in neuraxial management?

   1. Retract the epidural 1 cm

   2. Immediately replace with a new epidural

   3. Consider an epidural adjunct medication

   4. Immediately replace with a new combined spinal-epidural

2. A laboring patient receiving labor epidural analgesia with an epidural infusion containing a local anesthetic and opioid may still experience pain despite an appropriate sensory level tested with ice. Which condition may lead to central sensitization and altered perception of pain?

   1. Chronic exposure to opioids

   2. Preeclampsia

   3. Hypothyroidism

   4. Diabetes mellitus

Answers are provided at the end of the article.

DISCUSSION

The Society of Obstetric Anesthesia and Perinatology Practice Guidelines recommend use of epidural local anesthetics with or without opioids for labor analgesia.¹ Breakthrough labor pain occurs in up to 25% of parturients.² The causes are multifactorial, including technical, obstetric, and patient factors.^3,4 Epidural management strategies include administering additional local anesthetics, often with an adjunct medication, or repositioning or replacing the catheter.^1,2,5

Dexmedetomidine has gained attention as an epidural adjunct, shown to decrease parturient pain scores, pruritus, and nausea, but there is risk of maternal bradycardia.^6–8 Given the importance of addressing breakthrough labor pain, an off-label use of epidural dexmedetomidine, as detailed here, is valuable. There was no evidence of maternal hypotension, bradycardia, or neurologic complications in these cases. We saw an improvement in parturient pain control but did not assess specifically for pruritus or nausea.

We used a shared decision-making approach, explaining to the patients the option of adding an off-label medication to their epidural infusion to help with pain management. The patients agreed to proceed.

Difficult labor epidural placements, for example high BMI patients (case 1) or multiple epidural replacements (case 3), can increase risk of pain due to suboptimal catheter positioning impacting distribution of medication spread, or local tissue trauma caused by repeated insertion attempts.^9,10 Persistent gluteal and vaginal pain (case 1) and hip pain (case 2, 3) during labor was noted despite appropriate sensory blockade. Potential causes include incomplete sacral nerve root blockade, inadequate block density, and uneven anesthetic distribution.¹¹ Case 2 was further complicated by a history of chronic pain and opioid use, which may have increased the patient’s analgesic needs.¹² Epidural dexmedetomidine may be an option for augmenting block density and coverage in these patients.

Dexmedetomidine administration in each case increased block density and extended analgesia to previously spared regions without requiring an epidural replacement. Dexmedetomidine can act synergistically with local anesthetics, facilitating improvement in pain sensation.⁶ These scenarios suggest the potential utility of epidural dexmedetomidine as an adjunct for breakthrough labor pain, but more studies are needed to determine the generalizability to a variety of clinical scenarios. Epidural dexmedetomidine, as an off-label use, may play a role in management decisions in those who experience pain refractory to standard neuraxial strategies.

Answers to clinical questions

Question 1, c. These three cases highlight use of dexmedetomidine as an adjuvant medication to augment block density. Dexmedetomidine may be considered in unique scenarios, for example to enhance epidural analgesic effect and improve pain scores.⁶

Question 2, a. Chronic exposure to opioids can lead to central sensitization and altered perception of pain, which results in opioid-induced hyperalgesia.¹² These patients often require additional medication to control pain.

Disclosure statement/Funding

The planners and faculty for this activity have no relevant financial relationships to disclose. The authors report no funding. The patients consented to publication of this case series.