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A Multidisciplinary Approach to Designing a Protocol for Safe Labor and Delivery Management of a Patient with Idiopathic Anaphylaxis (IA) and Plasminogen Activator Inhibitor Type 1 (PAI-1) Deficiency
Abstract Number: F-02
Abstract Type: Case Report/Case Series
Summary: An interdisciplinary team created and implemented a labor and delivery plan for the successful management of a patient with IA and PAI-1 deficiency.
Background: This is a case of a 31-y.o. G1P0 patient with a past medical history of IA, PAI-1 deficiency, and heterozygosity for hemophilia A. IA is anaphylaxis not explained by a proved or presumptive cause or stimulus. The patient’s symptoms typically included urticaria and upper airway swelling that resolved with prompt administration of antihistamines and steroids. All of her medications were manufactured by a single pharmacy in another state.
PAI-1 is an important component of the coagulation system that down-regulates fibrinolysis. A reduction in the levels of PAI-1 may result in increased fibrinolysis and an associated bleeding diathesis. The patient had a history of menorrhagia and had received aminocaproic acid in the past as prophylaxis for dental procedures.
Clinical Course: The patient was admitted at 26 weeks with preterm contractions. She provided a list, created by her allergist, of medications and suppliers that were known to be safe as well as those known to induce allergic reactions. She received two doses of betamethasone, constituted by the pharmacy that usually makes all of her medications, prior to cessation of her contractions. She developed urticaria during her admission, thought to be due to the intravenous (IV) tubing. She was discharged and an interdisciplinary task force was formed to create a plan for her pending delivery.
The team included Obstetric Anesthesiology, Obstetrics, Hematology, Nursing, Pharmacy and Perioperative Services. The patient and her allergist were active participants in the protocol development.
The task force collaborated to identify and assemble medications and supplies safe for administration. Delivery scenarios were discussed among the team members and, in conjunction with the patient, a plan was created to manage each situation. A storage container dedicated to the patient was stocked with materials such as medications, sutures, DEHP-free IV tubing, and surgical instruments.
The patient returned at 29 weeks with premature preterm rupture of membranes and in labor. All involved team members implemented the previously generated plan. The patient had a spontaneous vaginal delivery of a baby boy with hemophilia A.
Discussion: Patients with IA present unique challenges for any surgical procedure. In addition, the presence of PAI-1 deficiency can complicate the anesthetic management of patients in labor. The interdisciplinary collaboration among multiple services resulted in a coordinated patient care plan to safely manage the labor and delivery of a patient with IA and PAI-1 deficiency.
1. Greenberger, P. Idiopathic Anaphylaxis. Immunol Allergy Clin N Am 2007; 27: 273-293
2. Mehta R, Shapiro A. Plasminogen activator inhibitor type 1 deficiency. Haemophilia 2008; 14: 1255-1260