Management of eight labor and delivery patients dependent on buprenorphine (Subutex™): A retrospective chart review

Patient 1

37yo G3P1 at 39-1/7 weeks gestational age (GSA) who presented with vaginal bleeding and genital herpes. She had a history of polysubstance abuse and was started on buprenorphine (BUP) 8mg PO daily by an outside provider. On the day of admission (DOA), she had an urgent Cesarean section (CS) for possible abruption and fetal intolerance. Intraoperatively, a single shot spinal (SSS) with 100mcg of preservative-free (PF) morphine added to 12 mg of bupivacaine and 10mcg of fentanyl failed to provide adequate anesthesia. Subsequently, a combined spinal-epidural (CSE) using only 10mg of bupivacaine for the repeat spinal anesthesia was placed. Unfortunately, the patient complained of sharp incisional pain despite a negative Allis test to the T4 dermatome. She was then converted to a general anesthetic (GA).

Her post CS pain management included BUP at her admission dose, PO OXY (15mg Q3H), APAP, and IBP. The patient additionally received three doses of 0.4mg IV HM to treat breakthrough pain. Her epidural was continued for 24 hours postoperatively with 0.0625% bupivacaine at 10ml/H. At this point, the patient had successfully transitioned to a PO pain regimen and the epidural was removed. She was discharged on POD 6 (reportedly with inadequate pain control) on her pre-operative BUP dose along with a 10-day supply of HM 2–4 mg PO Q4hrs (120 pills).

Two weeks after delivery, the patient was found pulseless and cold at a downtown hotel, and CPR was initiated for PEA arrest. The patient recovered to spontaneous circulation, and therapeutic hypothermia for 24 hours was initiated. Her MRI was consistent with anoxic brain injury demonstrating infarcts in the brainstem and cerebellum. A lumbar puncture was performed and creatine kinase bands (CK-BB) were exceptionally high. SSEPS noted an absence of cortical response. The patient was placed on comfort care and died 22 days after delivery. Donation of organs after cardiac death was declined. Opioid overdose was deemed the most likely etiology, based on the patient's history of heroin abuse and accounts from bystanders. OXY was identified in a post-arrest urine drug screen.

Patient 2

27yo G1P0 at 39-1/7 weeks GSA with a history of opioid dependence. She successfully completed an inpatient addiction treatment and was on BUP 8mg daily for one year. She was admitted for IOL in the setting of premature rupture of membranes (PROM). A CSE was placed on the DOA for labor analgesia and later an urgent CS was called for fetal distress. The epidural in situ was dosed for anesthesia in the operating room, but the patient reported a positive Allis test and consequently required a GA.

Post-operatively, the epidural was removed immediately since the epidural did not appear to provide operative anesthesia. She was not administered epidural morphine. Additional post-CS pain management included her pre-operative dose of BUP 8mg daily and a HM PCA; she was transitioned to PO OXY on POD 2. In addition, she did receive PO APAP and IBP throughout. On POD 1 she ambulated, met goals for symptom relief and was satisfied with her pain control. On POD 3, elevated blood pressures in the range of 120–150 mmHg systolic and 80–90 mmHg diastolic were measured and required treatment with furosemide and nifedipine.

She was discharged on POD 4 after a negative work-up of her hypertension. Discharge medications included a 7-day supply of OXY 5–15mg Q3H PRN (168 pills).

Patient 3

34yo G5P2 at 22-5/7 weeks GSA with a history of bipolar disorder, morbid obesity, bicorneate uterus, and heroin abuse on buprenorphine-naloxone (Suboxone^TM) 8mg daily. Her obstetric history included two prior CS’s and an IUFD. She was admitted for IOL with an IUFD at 22 weeks GSA. A CSE was placed for labor analgesia on the DOA and provided adequate pain relief, but as her labor progressed, she required multiple top-up boluses.

After an uneventful NSVD the patient required a dilation and curettage for retained products. Her epidural catheter in situ was successfully used for the surgery, and removed afterwards. Epidural morphine was not administered.

Post-op pain management included PO OXY, APAP, and IBP and her home dose of Suboxone was re-initiated; the patient had discontinued it upon hospital admission.

On POD 1 the patient was diagnosed with a post-dural puncture headache and received an epidural blood patch with good effect. She required 10mg of PO OXY on 3 occasions during her hospital stay; however, at discharge on POD 1 she was not prescribed opioids.

Patient 4

28yo G6P1 at 36 weeks GSA with cervical shortening, vaginal bleeding and pelvic pressure. She had a PMH significant for four years of BUP 8mg TID and alprazolam 1mg BID, opiate and benzo dependence, several 2nd trimester losses, and a CS at 40 weeks for 2nd stage arrest. She was diagnosed with an IUFD, and continued on her home dose of BUP and alprazolam while inpatient. The patient strongly desired GA for her CS.

Her post CS pain management included a ketamine infusion that was started intra-operatively at 8mg/H and continued post-op for 24H, a fentanyl PCA, PO APAP and IBP, as well as PRN IV lorazepam for anxiety. The patient’s PCA use of fentanyl included 4500mcg (1st 24H), 2600mcg (next 24H) and 3–6 mg IV lorazepam per day. On POD 2 the PCA was discontinued and PO HM was started. BUP was continued throughout her stay. The patient met goals for symptom relief and was satisfied with her pain control. She was discharged on POD 2 with a 10-day supply of HM 4mg PO Q6H (120 pills).

Patient 5

21yo G4P3 at 39 weeks GSA with a body mass index (BMI) of 44, a history of previous low transverse CS, followed by successful vaginal birth after CS (VBAC) twice before. She had a history of heroin abuse and was on BUP 4mg/day. In this pregnancy the fetus had been diagnosed with CDH (congenital diaphragmatic hernia). The patient desired a trial of labor after C-section (TOLAC) and received a CSE for labor analgesia. She remained on her pre-admission dose of BUP throughout her hospital stay. Due to the fetus’ likely poor prognosis, medical staff decided that expediting birth of the fetus would be the safest course of action. After the rupture of membranes and labor augmentation she delivered on the DOA. Unfortunately, the infant died within hours of birth due to complications from CDH.

Her postpartum pain management included PO OXY, APAP and IBP, as well as her outpatient dose of BUP. Pain remained well controlled with this regimen. Her mood was somber and she was grieving appropriately. Postpartum complications included elevated blood pressures without features of pre-eclampsia on post-partum day 1 (PPD). With well controlled pain and appropriate functional status, she was discharged three days after delivery. By the end of the hospital stay, she only required scheduled PO APAP and IBP for pain; she was discharged with no additional short acting opioids.

Patient 6

22yo G1PO at 30-6/7 weeks GSA who presented with preterm PROM. The pregnancy was complicated by heroin and methamphetamine abuse during the first trimester. After admission to the antepartum unit, her home dose of daily BUP 16mg for the remainder of her pregnancy was ordered. On the third day of the hospitalization, prolonged fetal decelerations prompted an urgent CS. A routine CSE was placed for CS anesthesia, and the surgery proceeded uneventfully. The spinal dose included bupivacaine 12.5mg, PF morphine 100mcg, and fentanyl 10mcg. Ketorolac 30mg IV was administered at the end of the case per routine protocol.

Her post CS pain management included an epidural infusion of bupivacaine 0.0625% at 10cc/H, a HM PCA, PO APAP and IBP and her daily home dose BUP. The patient’s pain was well-controlled and she was fully satisfied with pain management. After successful transition to PO HM the epidural was removed. The patient remained satisfied with her pain relief and was discharged on POD 2 with 36 tabs of 2mg HM.

The neonate was newly diagnosed with congenital anomalies including imperforate anus and esophageal atresia, with a VATER association. The patient stayed with her baby at the local children’s hospital and was unable to visit her distant provider for BUP refills. It was noted that she subsequently relapsed into her previous abuse pattern, within three months postpartum.

Patient 7

35yo G4P2 at 37-1/7 weeks GSA who presented for IOL in the setting of term IUFD in a previous pregnancy. She had a history of opioid dependence following an injury in the military requiring multiple reconstructive knee surgeries. She was placed on BUP 16mg daily for the remainder of her pregnancy and received this also throughout her hospital stay. During her IOL she received a CSE for labor analgesia, followed by an uncomplicated vaginal delivery 2 days after admission.

Her postpartum pain management included PO APAP and IBP and her daily home dose BUP; epidural was removed after delivery. She did not require additional PO opioids during her hospital stay and was discharged without any additional short acting opioids on POD 2.

Patient 8

34yo G1PO at 37-3/7 weeks GSA who presented with SROM. She had a history of opioid dependence following an MVA, in addition to current methamphetamine use. Her PMH was also significant for a congenital ventricular septal defect s/p surgery at age 1yo, with secondary pulmonary stenosis and a dilated right ventricle with mild dysfunction. In addition, the patient had a complex partial seizure disorder, tobacco use, and poor compliance with pregnancy care. She had been on BUP 2mg BID throughout the pregnancy, which was continued during her L&D stay. She received a CSE on the DOA for labor analgesia and required a CS for second stage arrest a day later; the epidural catheter in situ was successfully converted to provide anesthesia. She was not given epidural morphine.

Her post CS pain management included a HM PCA, an epidural infusion (0.1% bupivacaine at 8cc/H), PO APAP, IBP and her home dose of BUP. On POD 2 the epidural infusion was discontinued. On POD 3 she was transitioned to PO OXY and the PCA stopped. She was counseled not to use amphetamines while breastfeeding. On POD 5 she was discharged to home with 30 tabs of 5mg OXY, with the plan of continuing BUP in the outpatient setting. In the following days, she returned to clinic requesting additional opioids due to breast pain; she was subsequently prescribed 20 tabs of 5mg OXY.