Anesthésie ďune parturiente en travail, atteinte ďurticaire pigmentaire

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. 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]

Clinical Impact of Pregnancy in Mastocytosis: A Study of the Spanish Network on Mastocytosis (REMA) in 45 Cases

“…As previously described [17,19,22], our results show that anesthetic procedures and drugs given for inducing labor appear to be safe for the use in pregnant women with mastocytosis. In fact, only 3 women suffered from MC-related symptoms intrapartum when epidural anesthesia was used; interestingly, no prophylactic antimediator therapy was given to 2 of them.…”

“…Moreover, the compulsory discontinuation of antimediator drugs during pregnancy because of safety concerns, the stress of labor, and the potential administration of anesthetic and analgesic drugs in its management, may also worsen MC mediator-related symptoms. However, information on pregnant women with mastocytosis is restricted to a small patient series [17] and some case reports [18,19,20,21,22]. …”

Anesthetic considerations in pediatric mastocytosis: a review

“…Over one-half of children with mastocytosis are symptomatic, and the most common symptoms include flushing and pruritis, mostly related to mastocyte release of histamine, prostaglandin-D2 (PG-2), and leukotriene-C4 [1,4,[16][17][18][19]. Bronchospasm, a typical sequela of IgE-mediated reactions, it not a common mediator-related incident in mastocytosis [17,20,21]. Children often report gastrointestinal symptoms, for example abdominal pain and diarrhea, and neurologic manifestations including mental status changes, syncope, and seizures under stress conditions [5,22,23].…”

“…Sufentanil was first implicated as an initiator in 2001 after repeat exposure of an infant with bullous mastocytosis (see above) [45]. Propofol, a routinely-used intravenous induction agent which is increasingly recognized as a cause of anaphylaxis and has been shown to cause histamine release in vivo, is regarded as a safe alternative in the mastocytosis patient population [21,48,74,75]. Intravenous midazolam 0.2 mg/kg has been shown to induce histamine release in a susceptible adult patient population but has also been used safely in children with mastocytosis [15,27,76,77].…”

“…Following the first reports of cardiac arrest in mastocytosis patients undergoing anesthesia and surgery in the 1990s, most experts advocate that cardiovascular decompensation should be a foreseeable concern in all cases, including pediatric anesthesia cases in which current evidence suggests major side effects are unlikely [21,27,41,42,85]. Epinephrine should be on hand for all mastocytosis patients in the perioperative period; in addition to giving cardiovascular support, epinephrine may hinder mast cell degranulation via b 2 -adrenergic receptor stimulation [41].…”