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///2012 Abstract Details
2012 Abstract Details2019-08-02T19:38:42-05:00

Anesthetic Management for Cesarean Delivery of a Parturient With Severe Impetigo Herpetiformis

Abstract Number: T-64
Abstract Type: Case Report/Case Series

Adrienne T. Duffield MD1 ; Kathleen A. Smith MD2

Case report:

A 19 year old G1 presented for cesarean delivery at 33 weeks gestation. She was admitted 3 weeks prior with diffuse erythematous plaques, which spread to involve her entire body despite escalating corticosteroid and cyclosporine therapy. On exam, she had poor mouth opening secondary to pain. Given the lesions on her back and history of MRSA positive cultures, a general anesthetic was planned. After an uneventful rapid sequence induction, successful videolaryngoscopy and intubation were performed with a C-MAC. Her operative course was otherwise uneventful. She was discharged 1 week postoperatively with prednisone and cyclosporine. The neonate required mechanical ventilation, but was extubated and discharged on day of life 35.

Discussion:

Impetigo herpetiformis (IH) is a severe, generalized pustular skin eruption of pregnancy. With less than 200 reported cases, it remains an exceedingly rare entity and presents unique challenges to the obstetrical anesthesiologist. Prior to immunosuppressive and antibiotic therapy, maternal prognosis was grim, with mortality approaching 70-90%. Fetal outcomes remain poor, as placental insufficiency can result in intrauterine growth retardation and fetal demise[1].

Whether cesarean section is emergent or elective, anesthetic planning should address 1) safe airway management and 2) proper positioning and monitoring with attention to care of compromised skin. While successful delivery under spinal anesthesia has been reported[2], our patient's history of MRSA infection and the presence of potentially superinfected lesions over the lumbar spine precluded a regional anesthetic. Pharyngeal and laryngeal edema can accompany severe disease, raising concern for difficult mask ventilation and intubation[3]. While successful videolaryngoscopy was performed, an awake fiberoptic would have been appropriate if the patient had other markers of a difficult airway. Additional challenges arose with the application of monitors. The blood pressure cuff was placed on the upper arm after it had been wrapped in cotton padding. ECG leads were placed over lubricated skin, using caution to avoid areas with severe lesions. The pulse oximeter was relegated to the left ear, as the finger nail beds were completely eroded. The ETT was secured with cotton twill obtained from our burn unit. These precautions, in conjunction with attention to positioning, prevented further denuding of the skin.

References:

1. Ingber, A. Obstetric Dermatology, A practical guide. Impetigo Herpetiformis, 135-141. Berlin: Springer-Verlag, 2009.

2. Pemberton O, Callender C. A Caesarean section under spinal anaesthesia for a patient with pustular psoriasis. Anesthesia, 2009;64:793-813

3. Samieh-Tucker A, Rupasinghe M. Anaesthesia for caesarean section in a patient with acute generalised pustular psoriasis. Intern J Obstetric Anesth, 2007;16:375–378

SOAP 2012