Abstract
Purpose
To report the anesthetic management of labour pain and Cesarean section in a patient with urticaria pigmentosa at risk for systemic mastocytosis.
Clinical
A 37-yr-old patient with a history of urticaria pigmentosa and an allergic reaction to a local anesthetic agent was seen in consultation at 36 weeks gestation. She previously tested negative for an allergy test to lidocaine. Recommendations to avoid systemic mastocytosis included: avoidance of histamine-releasing drugs, using lidocaine for labour epidural, and regional anesthesia in case of a Cesarean section. The patient presented at term in labour. Intravenous fentanyl was used for early labour, followed by a combined spinal-epidural. The spinal contained lidocaine and fentanyl, but because of pruritus, the epidural infusion contained lidocaine only. Most likely because of tachyphylaxis to lidocaine, an epidural bolus of lidocaine with epinephrine failed to provide adequate anesthesia for a Cesarean section. The block was supplemented with nitrous oxide by mask, with fentanyl postdelivery. Postoperative pain control was managed with an epidural infusion of lidocaine and fentanyl for three days. The patient was discharged without complications four days postsurgery.
Conclusion
Proper allergy testing prior to pregnancy is important to help the management of labour pain and anesthesia for Cesarean section in a patient at risk for systemic mastocytosis.
Résumé
Objectif
Présenter ľanesthésie utilisée pendant la césarienne pour contrer la douleur chez une patiente atteinte ďurticaire pigmentaire à risque de mastocytose diffuse.
Éléments cliniques
Une femme de 37 ans, ayant déjà eu de ľurticaire pigmentaire et une réaction allergique à un anesthésique local, a consulté à 36 semaines de grossesse. Un test antérieur ďallergie à la lidocaïne s’était révélé négatif. Pour éviter la mastocytose diffuse, il faut éviter les médicaments à libération ďhistamine, utiliser la lidocaïne pour ľanesthésie épidurale pendant le travail et ľanesthésie régionale en cas de césarienne. La patiente en travail a été hospitalisée au terme de sa grossesse. Du fentanyl intraveineux a été utilisé au début du travail, puis une anesthésie rachidienne et épidurale combinée. Ľanesthésie rachidienne comprenait de la lidocaïne et du fentanyl, et ľanesthésie épidurale, de la lidocaïne seulement. Sans doute à cause ďune tachyphylaxie à la lidocaïne, ľanesthésie avec un bolus épidural de lidocaïne et de Ŀépinéphrine n’a pas suffi pour la césarienne. Le bloc a été complété avec du protoxyde ľazote, administré au masque, et du fentanyl après ľaccouchement. La douleur postopératoire a été contrôlée par une perfusion épidurale de lidocaïne et de fentanyl pendant trois jours. La patiente n’a subi aucune complication et a quitté ľhôpital quatre jours aprés la césarienne.
Conclusion
Des tests ďallergie appropriés, faits avant la grossesse, sont importants pour décider du contrôle de la douleur du travail et de ľanesthésie pour la césarienne de patientes à risque de mastocytose diffuse.
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Villeneuve, V., Kaufman, I., Weeks, S. et al. Anesthetic management of a labouring parturient with urticaria pigmentosa. Can J Anesth 53, 380–384 (2006). https://doi.org/10.1007/BF03022503
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DOI: https://doi.org/10.1007/BF03022503