Introduction

Acetaminophen is an effective analgesic and antipyretic agent with few adverse effects (₁).

After caesarean section, parenteral acetaminophen, opioids and NSAIDS are commonly used for postoperative analgesia (₂,₃).

In pregnant patients and postpartum pariod; paracetamol usually used for fever.

In this case report; we discussed the treatment of fever and postoperative pain with paracetamol infusion in a pregnant patient with fetal distress.

Case Report

A 26 year-old, gravida 1, 31 weeks pregnant women, presented to the hospital with fever, uterin tenderness and sanies vaginal flow. She had a high-grade fever for 3 days prior to admission (38.5°C ). She was first seen at antenatal clinic at 12 weeks pregnancy, and there was no abnormality detected until this presentation. Her past medical and family history were unremarkable.

On admission, her temperature was 38.5°C, blood pressure was 120/75 mmHg and pulse rate was 128/min. Fetal distress was observed.

Laboratory analysis on admission gave the following results: hemoglobin 11.9 g/dl, hematocrit 35%, white blood cells count 17,600/mm ³ , platelet count was 178000 / mm ³ .

Chorioamnionitis was identified and becouse of fethal distress; the patient was taken to caseraen section urgently.

In the operating, standart monitoring (ECG, Sp0_2, and non-invasive arteriel pressure) was used. Her temperature was 38°C. An appropriate antibiotics was begun to use and treatment continued after the operation.

Systolic, mean, diastolic arteriel pressures, heart rate, temperature and pulsoximetre were recorded every 5 minutes during operation. Her maximum temperature was 38°C.

The baby had APGAR scores 9 and 10 at 1 and 5 minutes, respectively. No abnormality in newborn was detected.

After the umblical cord was clamped, 1g/100ml iv paracetamol ( Perfalgan, Bristol Myers Squibb, München, Germany) was given to the patient. She had no pain after the operation. Her temperature was 38.5°C in the recovery room. Paracetamol was given at 6-h interval. Temperature was recorded. On the same day tempearture began to decrease to 37°C. The pain score on a visuel analogue scale (VAS; 0-10 cm; 0= no pain and 10= worst possible pain) was maximum 5. After two days in postnatal care her temperature and leukocystocis decreases to 36°C and 7000 mm ³ and there was no pain. For the next two days paracetamol infusion was used. After 10 days the patient discharged from hospital without pain and fever.

Discussion

In this case report we must discussed two problems. The first problem was chorioamnionitis and the second was pain after caesarean section.

Chorioamnionitis represents infection of the chorionic and amniotic membranes, and may involve the placenta, uterus, umblical cord and fetus. It complicates up to 1-2% of pregnancies. The principal maternal complications of chorioamnionitis are dysfunctional labor, often leading to cesarean section, intra-abdominal infection, septicemia and postpartum hemorrhage. Fetal complications include premature labor, acidosis, hypoxia and septicemia (₄).

Effective pain management is an important component of postsurgical care. Many patients, however, continue to experience inadequate pain relief (₅). Despite improvements in analgesic delivery, several recent surveys have found that up to 80% of patients report moderate to severe pain after surgery (₆,₇,₈).

Effective analgesia is important after caesarean section to provide the mother, early ambulation and discharge, hence leading to greater overall patient satisfaction.

After caesarean section, parenteral acetaminophen, opioids and NSAIDS are commonly used for postoperative analgesia (₅,₆).

Opioids remain the agents of choice for severe pain; however, this class of analgesics is associated with dose-dependent adverse effects such as nausea, vomiting, ileus, sedation and respiratory depression and prolong the time to readiness for discharge (₇,₈).

Nonopioid analgesics (acetaminophen and NSAIDS) are commonly used alone or as adjuncts to opioid-base analgesia to treat moderate to severe pain (₈).

Acetaminophen has a well-established safety and analgesic profile. It has few contrindications and lacks significant drug interactions (₉,₁₀).

Perfalgan (1g/100ml) is an injectable paracetamol solution in a unit-dose form, ready for infusion. It was introduced into clinical practice in 2002.

In pregnant women and for postpartum period paracetamol was the first choice for fever and analgesia.

Iv administration of paracetamol has already demonstared its analgesic efficiency in patients with postoperative pain following gynecologic surgery (₁₁).

Varrassi et al (₁₁) compared the analgesic efficiency and tolerability of proparacetamol and ketorolac after gynecologic surgery. In this study they demostrate that the relative morphine requirement of the proparacetamol group was similar to that of the ketorolac group. This suggests that proparacetamol is effective in the management of postoperative pain when combined with an opioid analgesic. Side effects were all similar.

After caesarean section, breast feeding was another problem. The agents must not transfer to the baby with milk. Paracetamol can be used in breast-feeding women(₁₂).

We report the management of fever and analgesia in a pregnant woman. The patients pain and fever treated succesfully with usage of iv paracetamol infusion. We suggested paracetamol infusion for fever and pain after caesarean section.

Correspondence to

Mehmet Turan INAL, MD Address: Etimesgut Military Hospital, Department of Anesthesiology and Reanimation Etimesgut/Ankara/Turkey Tel: +903122491011 Fax: +903122444977 e-mail: mehmetturaninal@yahoo.com