Management of severely painful uterine leiomyoma in a pregnant woman with epidural block using a subcutaneous injection port

Sir Pain is the most common complication of leiomyoma in pregnancy (1). Severe abdominal pain can occur if a leiomyoma undergoes degeneration, which occurs in 5–8 of leiomyomas during pregnancy (2,3). We wish to call attention to successful severe pain management by epidural administration of a local anesthetic via a subcutaneous injection port in a 32-year-old primigravida who had degeneration of uterine leiomyomas at 23 weeks pregnancy. She had been referred to our hospital because of uncontrolled abdominal pain. On axial T2-weighted MRI imaging, two 14 9 9 cm and 11 9 8 cm intramural myomas with degeneration were detected in the right lateral and postero-inferior body of the uterus. The degree of her abdominal pain was 910 on a visual analog scale (VAS) and she had regular uterine contractions. She was treated with intravenous ritodrine hydrochloride for the preterm contractions. Acetoaminophen, codeine and even intravenous pethidinemeperidine failed to control her pain. At our pain clinic we administered local anesthesia by epidural and patient controlled analgesia (PCA) was initiated with a dose of fentanyl 6 gh and 0.25 ropivacaine 6 mLh. The pain improved dramatically to a VAS degree 210. Considering the risk of infection associated with a percutaneuous epidural catheter, we used the epidural catheterization with a subcutaneous injection port. The epidural catheter was tunneled into the subcutaneous tissue under local anesthesia and connected to the port, which was implanted in the left lower abdomen. The PCA was connected to the port, and we administered 0.25 ropivacaine, 6 mLh without fentanyl. Antibiotic cover was given. The patient achieved adequate pain relief using this implanted port for 22 days and was scheduled for discharge. Unfortunately, preterm premature rupture of membrane occurred at 27 weeks gestation. Three days later the amniotic fluid index was <2 cm and variable fetal heart rate decelerations were noted, prompting an emergency cesarean section. The baby, weighing 940 g with Apgar score of 2 and 4 at 1 and 5 min, respectively, died in the neonatal unit 1 week later. Epidural analgesia has been applied for severely painful leiomyoma during pregnancy before (4), but epidural catheterization with a subcutaneous injection port in pregnant women has not been reported. Our patient improved and successfully retained the epidural catheterization with a subcutaneous injection port for 27 days.