///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Labor Anesthesia in a Patient with Severe Chronic Psoriasis, Asthma, Morbid Obesity, and Twin Gestation

Abstract Number: 91
Abstract Type: Case Report/Case Series

Christopher G Hughes M.D.1 ; Curtis Baysinger M.D.2

Introduction

Few reports of cesarean section under general anesthesia (GA) for patients with generalized pustural psoriasis exist; however, reports describing neuraxial blockade in the parturient suffering from severe chronic psoriasis with active lumbar lesions are absent.

Case Description

A G3P2 woman with 34 week twin gestation presented in labor with pustular psoriasis, severe pre-eclampsia, asthma, gastric reflux disease (GERD), tobacco abuse, and 48 kg/m2 BMI. Psoriasis involved 90% of her total body surface area. Her cervix was 80% effaced and dilated to 6 cm. Magnesium, hydralazine, albuterol, betamethasone, and penicillin G therapy were initiated.

Psoriatic plaques covered her abdomen and back with diffuse erythema, pustules, and excoriation (Figure I). Airway assessment noted a modified mallampati score III/IV, large tongue, short thyromental distance, and significant facial edema. Expiratory wheezes were heard on auscultation.

The patient was counseled on the increased risk of infection for neuraxial anesthesia. In the sitting position, her back was generously prepped with iodine povacrylex and isopropyl alcohol, gently removing loose tissue without causing further skin breakdown. A combined spinal epidural (CSE) technique was utilized with the catheter secured using adhesive and biocclusive dressings.

The patient remained comfortable during labor with the epidural infusion. Once her cervix dilated to 10 cm, she was transported to the operating room where she delivered twins. The epidural catheter was pulled with no evidence of infection. She was discharged 5 days postpartum without apparent sequelae from severe pre-eclampsia or exacerbation of her psoriasis.

Discussion

Several factors led to the obstetrical decision to attempt vaginal twin delivery under neuraxial analgesia. The patient strongly preferred vaginal delivery. While the severe psoriasis likely increased her risk of wound infection, no signs of active infection were present. Her uncontrolled asthma, tobacco abuse, GERD, and potentially difficult airway greatly increased the risk of GA, a strong possibility with the increased risk of emergent cesarean section due to her severe pre-eclampsia. The patients extreme discomfort, rapidly progressing labor, and high risk for operative delivery justified the use of a CSE. In summary, we report the successful utilization of CSE anesthesia in an obstetric patient with severe chronic psoriasis and lesions at the site of placement.



SOAP 2009