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. U RTICARIA pigmentosa is the cutaneous manifestation of mastocytosis, a disease characterized by the proliferation and accumulation of mast cells in various organs of the body. The incidence of urticaria pigmentosa has been reported to be between 1 in 1,000 and 1 in 8,000 of the population. 1 As many as 10% of patients with urticaria pigmentosa will have systemic
Objectif
Obstetrical and Pediatric AnesthesiaAnesthetic management of a labouring parturient with urticaria pigmentosa [Anesthésie d'une parturiente en travail, atteinte d'urticaire pigmentaire]
An L4-5 epidural catheter initially provides less relief of abdominal pain but more relief of perineal labor pain. Patients with an L4-5 catheter require more manual boluses during early labor but less during late labor. The possible association of low epidural catheters with instrumental delivery merits further investigation.
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