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Obstetrical Analgesia in a Parturient with Leprosy (Hansen’s Disease)
Abstract Number: F-33
Abstract Type: Case Report/Case Series
We present the case of a 42 year old parturient with Hansen’s disease (leprosy) who requested a continuous lumbar epidural (CLE) for pain control in labor. We include a short description of the disease and the implications for obstetric anesthesia. A 42 year old, 84-kg, ASA physical status II, G5P3, Hispanic female from Mexico was admitted in spontaneous labor at term. Two years prior to this admission she presented with bilateral lower extremity pain and weakness, with occasional fevers and a rash of 2-3 months duration. On exam she had 0.3-1.5 cm erythematous raised lesions on both lower extremities. She was then followed over the next few months and eventually the diagnosis of leprosy was confirmed. The patient was started on standard multi-drug therapy (rifampin & clofazipine) but developed severe erythema nodosum leprosum (ENL) and was admitted to our medical intensive care unit, where she was stabilized and eventually discharged. At some point prior to her current pregnancy she discontinued medical therapy. A multidisciplinary conference of maternal-fetal medicine, infectious disease and anesthesia was held. It was decided there were no absolute contraindications to regional anesthesia and the patient could receive epidural or spinal analgesia if requested. Upon presentation in labor she complained of tingling and paresthesias in her lower extremities and hands plus chronic lower extremity pain and ankle edema. On examination her cervix was noted to be dilated 5cm, 100% effaced, with the head at -1 station. Vitals signs were BP= 155/77 mmHg; HR= 115 beats/min; O2 saturation= 94% on room air. Laboratory values were: Hgb/Hct 12.2/36.3g/dl; WBC12.7; platelets= 248; urinalysis showed 1+ protein; The fetal heart rate was in the 130’s and initially showed good variability but progressed to deep variable decelerations for which she received terbutaline followed by an amnio-infusion. The decelerations subsided. A continuous lumbar epidural was placed. It was secured and a patient controlled epidural analgesia infusion (0.1% bupivacaine + 2mcg/ml of fentanyl) was started. The patient had good resolution of pain and minimal motor block.
The most recent data from the CDC states that the known cases of Hansen’s disease were 763,917 worldwide. The United States (US) reported 96 cases in the same period. In 2002 WHO listed Brazil, Madagascar, Mozambique, Tanzania, and Nepal as having 90% of the documented cases. The infectious agent is a bacillus, Mycobacterium leprae, which is known to multiply slowly and affect the skin, nerves and mucous membranes. The increase in world travel means increased exposure to rare tropic diseases. Leprosy presents several challenges to anesthesia providers including peripheral and autonomic neuropathy, cardiac conduction abnormalities and the theoretical risk of introducing infectious agent into the CNS. We discuss these issues.