Remifentanil-induced fetal heart rate changes during labor in a patient with active malaria and thrombocytopenia: a case report.

Malaria-associated thrombocytopenia may preclude neuraxial labor analgesia, leaving remifentanil intravenous patient-controlled analgesia as the primary alternative. The effect of remifentanil on fetal heart rate is incompletely characterized. We report a 31-year-old primigravida at 36 weeks gestation with active Plasmodium falciparum malaria and a platelet count of 64,000/μL who received remifentanil for labor analgesia. Category III fetal heart rate tracings occurred twice, five hours apart, at bolus doses of 0.14 and 0.18 μg/kg with a 2-min lockout period, in the absence of maternal side effects. Both times, fetal heart rate normalized within 10 min of discontinuation, averting cesarean delivery. The patient vaginally delivered a healthy neonate. Remifentanil can produce severe, rapidly reversible fetal heart rate changes at standard doses. Prompt recognition and discontinuation are essential in higher-risk populations where neuraxial analgesia is contraindicated.