Abstract

Background and Clinical Significance: Uterine atony is the most frequent cause of postpartum hemorrhage and remains a major contributor to maternal morbidity worldwide. Neuraxial opioids are routinely used as adjuvants for labor analgesia and cesarean delivery anesthesia; however, their possible influence on myometrial contractility remains incompletely clarified. We describe a severe case of refractory uterine atony after emergency cesarean delivery in a patient exposed sequentially to epidural fentanyl during labor and intrathecal morphine for cesarean anesthesia; Case Presentation: A 34-year-old primigravida at 39 weeks and 4 days of gestation presented with early labor that had begun less than one hour earlier. Epidural labor analgesia was provided with ropivacaine, and the total epidural fentanyl exposure was 100 mcg over an approximately 7 h catheter period. Labor was complicated by dysfunctional uterine activity and cervical dystocia despite 3 h and 30 min of oxytocin augmentation. Emergency cesarean delivery was performed under spinal anesthesia with hyperbaric bupivacaine and intrathecal morphine. After delivery of a healthy neonate and uncomplicated placental separation, the patient developed severe uterine atony with postpartum hemorrhage. Hemorrhage persisted despite uterotonic therapy, continuous uterine massage, hemostatic suturing, and B-Lynch compression suture. Blood loss, measured using the suction canister and estimated from surgical swabs, was approximately 3800 mL. Progressive hemodynamic instability required transfusion therapy, conversion to general anesthesia, norepinephrine support, and emergency total abdominal hysterectomy. The postoperative course was favorable, and the patient was discharged on the eighth postoperative day; Conclusions: This case illustrates the rapid progression and therapeutic complexity of refractory uterine atony after emergency cesarean delivery in the setting of dysfunctional labor, oxytocin augmentation, cesarean delivery, sequential neuraxial opioid exposure, and subsequent hemorrhagic instability. A possible contribution of sequential neuraxial opioid administration to impaired myometrial contractility cannot be excluded; however, causality cannot be established from a single case. Early recognition, structured escalation, transfusion support, and timely multidisciplinary surgical management remain essential in severe postpartum hemorrhage.

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