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Hereditary angioedema, local anesthetic allergy and allergy testing in pregnancy
Abstract Number: T-63
Abstract Type: Case Report/Case Series
The case highlights the changes in frequency and severity associated with hereditary angioedema (HAE) attacks in pregnancy, the treatment available, and the scarcity of information in the literature.1 Cross reaction of amide local anesthetics and timing of allergy testing in pregnancy is also discussed.2,3
A 36-year-old woman G1P0 presented at 37+6 weeks for induction of labor. The patient had a past medical history of HAE. Her HAE attacks started at age 12 when she developed bronchospasm at the dentist following an injection of local anesthesia. It was not known if this was an allergy to local anesthesia or a triggering of an attack of HAE. The patient then had 4-5 attacks a year, mainly affecting her upper limbs and her gastro-intestinal tract. The patient’s attacks were well controlled with diclofenac suppositories. In pregnancy the patient suffered increasingly frequent attacks. The attacks were every 3 days in the first trimester every 4 days in the second trimester and she experienced one severe attack in the third trimester associated with the flu. Local anesthetic allergy testing was performed at 21 weeks and showed an equivocal reaction to lidocaine and no reaction to bupivacaine. The case was discussed at length with the obstetrician and the allergist. The anesthesia team advised an elective cesarean section (C/S), with combined spinal epidural using bupivacaine only, but the patient was keen to deliver vaginally. An epidural was placed early with bupivacaine used for skin infiltration, test dose and continuous infusion. If she required an urgent or stat C/S we planned to use chloroprocaine. For the severe attack in the third trimester she took CINRYZE (C-1 esterase inhibitor concentrate). On advice of the care team the patient took CINRYZE the night before she came into the hospital for induction. Diclofenac was discontinued in the third trimester due to its potential to cause premature closure of the ductus arteriosus. The patient also had Icatibant on standby, purchased from outside the US. She delivered uneventfully by NSVD.
HAE attacks may increase in frequency and severity in pregnancy. Treatments available are expensive and few are approved in the US or during pregnancy. Only a few case reports are available in the literature of CINRYZE being used in pregnancy.1 In true allergic reactions to amide local anesthetics, cross reaction may occur. The pattern is different in every patient.2 Timing of local anesthesia allergy testing is controversial during pregnancy. Ideally it should be done pre-pregnancy, if this is not possible it should be performed at 38 weeks. It should be done in an operating room fully equipped and staffed for an emergency C/S if required.3 This was not the case with our patient.
1 Cedric Hermans. Arch Gynecol Obstet 07;276:271–276
2 P. González-Delgado. J Investig Aller Clin Immunol 06;Vol.16(5):311-313
3 Philip Balestrieri. Allergy Anesth Analg 03;96:1489-9