Anaphylaxis during pregnancy is uncommon and poses a great dilemma. The conundrum of drug therapy, optimal timing of delivery, and method of anesthesia is still unresolved. We report such a case of 30-year-old hypothyroid parturient at 36 weeks and 5 days of gestation, with a history of uneventful previous lower segment cesarean section (LSCS). She was having scar tenderness and fetal distress and was being prepared for planned emergency LSCS. She had an anaphylactic reaction to ceftriaxone and developed cardiorespiratory failure. The manuscript highlights the different dilemmas and discusses management options.
Keywords: Anaphylaxis, anesthesia, labor, obstetric, perioperative, shock
|How to cite this URL:|
Poonuraparampil JA, Reazaul Karim HM, Garhwal A, Babu MJ. The conundrum of perioperative management for emergency cesarean section in a patient with anaphylactic shock. Bali J Anaesthesiol [Epub ahead of print] [cited 2021 Apr 22]. Available from: https://www.bjoaonline.com/preprintarticle.asp?id=293616
| Introduction|| |
Anaphylaxis has been defined as a serious, generalized or systemic, allergic, or hypersensitivity reaction that can be life threatening or fatal, or simply as a serious allergic reaction that is rapid in onset and may cause death., Anaphylaxis during pregnancy is a rare event. Further, anaphylactic shock in the immediate preoperative period in a patient who required an emergency lower segment cesarean section (LSCS) is rarely described. This is a challenging situation and possible options for different dilemmas.
| Case Report|| |
A 30-year-old female was on her second pregnancy at 36 weeks and 5 days of gestational age, with previous LSCS presented in active labor. Scar tenderness and fetal distress were noted, and emergency LSCS was planned. She is also hypothyroid, on tablet Thyroxine 50 μg, and denied any known allergies; previous LSCS was uneventful. A subcutaneous antibiotic sensitivity test was done for ceftriaxone, which was planned for chemoprophylaxis just before shifting to the operating theater (OT). Within minutes, the patient complained of chest discomfort, difficulty in breathing, and nausea. Local skin was erythematic with urticarial rashes over the limb and flushed face. Eye redness was also noticed.
The anesthesiologist was immediately called, and meanwhile, the patient received injection hydrocortisone 100 mg and chlorpheniramine maleate 10 mg and was transported to the OT. Although there was mild symptomatic relief, the attending anesthesiologists' evaluation indicated poor patient conditions and suspicion of ongoing anaphylactic shock. On arrival to the preoperative area, her room air peripheral oxyhemoglobin saturation (SpO2) was 75% and blood pressure (BP) of 75/40 mmHg, with heart rate (HR) and respiratory rate of 110 and 36/min, respectively. Chest auscultation revealed bilateral wheeze with minimal basal crepitations.
Adrenaline 0.5 mg (1:1000) was immediately injected intramuscularly, and oxygen at 10 L/min through mask was started. An additional 16G catheter line was secured. Further consultation with senior and help was sought, and with informed high-risk consent, the patient was shifted to the OT table. The American Society of Anesthesiologists standard monitoring was applied along with invasive BP was instituted; SpO2 improved to 94% and BP to 88/48 mmHg. The surgical team was asked to get readied for incision, while preoxygenation was started. General anesthesia (GA) was induced using propofol of 100 mg, followed by succinylcholine 75 mg with cricoid pressure, and the airway was secured with a 6.5 mm endotracheal tube, and controlled mechanical ventilation was started after confirmation. Meanwhile, the surgeon started the procedure. Fentanyl 50 mcg was injected and sevoflurane on 100% oxygen added to achieve age-adjusted minimum alveolar concentration of 0.8 during maintenance.
With the delivery of the fetus, oxytocin 10 IU in 500 mL Ringer's lactate intravenous slow infusion was started. A single female baby was born with the 1st min APGAR score of 5, which improved to 9 at 5 min with resuscitation and shifted to the neonatal intensive care unit (ICU) for further care. A further 10 IU oxytocin intramuscular was administered as per the surgeons' request. However, the surgeon was not comfortable with the uterine contraction, so intramuscular methylergometrine 0.2 mg was also administered.
Hypotension was not responding well to phenylephrine, and patients' systolic BP reached 40 mmHg with HR of 48 bpm. Intravenous adrenaline 1 mg (diluted in 10 mL) was administered, which improved the BP transiently. Considering the critical condition of the mother, ultrasound-guided right internal jugular vein was catheterized, and noradrenaline was started and titrated to maintain the mean BP around 65 mmHg. Furosemide 10 mg and nalbuphine 3 mg were also administered at the end of surgery.
Postoperatively, the patient was shifted to the ICU where her condition gradually and steadily improved with further supportive and conservative management. She was extubated on the 3rd postoperative day and shifted out of the ICU on the 4th postoperative day. Both mother and baby were discharged in good health on the 10th postoperative day.
| Discussion|| |
Our patient had an anaphylactic reaction to ceftriaxone, followed by shock. Beta-lactam antibiotics have been implicated as the most common trigger for anaphylaxis during pregnancy. Anaphylaxis is a relatively uncommon event during pregnancy, with a prevalence of 2.7 cases/100,000 deliveries. General management of anaphylaxis in pregnant women is indifferent to nonpregnant patients. However, the conundrum for the administration of adrenaline and timing of delivery does exist. Adrenaline is the drug of choice for anaphylaxis but can cross the placenta and pose a risk to the fetus. The clinical dilemma of either proceeding for the immediate cesarean section or stabilize the mother to some extent before proceeding for the cesarean section is also an unresolved issue. Conservative management of maternal anaphylaxis in the third trimester has been reported where the fetus was not in distress. However, in the present case, there was limited scope to wait as the baby was already in distress, and the mother had scar tenderness. Moreover, our patient was also in shock and hypoxia. These conditions can predispose the neonate to permanent brain damage., As the baby was already in a viable gestational age, there was no better way than to perform immediate LSCS to reduce further fetal harm.
Our patient did not respond so well to adrenaline and was rapidly deteriorating. It is suggested that rapidly progressing anaphylaxis is fundamentally less responsive to adrenaline., Pregnancy and thyroid disease are regarded as a potential risk for increased severity and fatality from anaphylaxis which probably explains it. Noradrenaline infusion is advised for persistent hypotension and shock despite administering adrenaline for acute management of anaphylaxis.
The other clinical dilemma was the choice of anesthesia. Both GA and regional anesthesia (RA) can further affect hemodynamics. Further, inducing and maintenance anesthetic agents for GA are cardiodepressant. Furthermore, pregnancy is a high-risk situation for airway and related mortality. A population-based study also implicates GA for a poor neonatal outcome, especially when the fetus is already compromised in utero. On the other hand, epidural anesthesia (EA) has minimal effect on hemodynamics, and RA is regarded as a better option than GA for a cesarean section; the present patient condition and situation were not much favorable for RA. Further, the major neonatal and maternal outcome is similar in GA versus RA. The patients' condition was in shock, hypoxic, and impending cardiorespiratory arrest. Therefore, emergency airway management is most likely to be required, even if proceeded with RA. Nonetheless, EA in an emergency situation, also in a relatively uncooperative patient, might not be feasible. Hence, we had to proceed with GA with precautions, and as expected, the patient further collapsed and required both respiratory and cardiovascular support.
| Conclusion|| |
The emergency cesarean section in a parturient who is in anaphylactic shock is a dilemmatic situation. GA, although risky, appears to be a better feasible option in the situation. Such a patient needs immediate multidisciplinary and intensive management. Noradrenaline infusion is helpful in persistent hypotension/shock due to anaphylaxis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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Habib Md Reazaul Karim,
Faculty Room A001, Block A, All India Institute of Medical Sciences, Raipur - 492 099, Chhattisgarh
Source of Support: None, Conflict of Interest: None