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MASTOCYTOSIS AND IMPLICATIONS FOR THE OBSTETRIC ANAESTHETIST
Abstract Number: T-25
Abstract Type: Case Report/Case Series
Mastocytosis is a rare disorder of mast cell proliferation & accumulation with a spectrum of clinical manifestations ranging from cutaneous symptoms through to severe bronchospasm and cardiovascular collapse. Stimuli include trauma, emotional & physical stress, pain, temperature extremes & pharmacological agents.
A 35 year old primagravida with cutaneous mastocytosis & needle phobia presented to anaesthetic pre-assessment services at 26 weeks gestation. She experienced predominantly skin manifestations but reported intermittent systemic symptoms. These included abdominal pain, fatigue, syncope, & palpitations. Her triggers were innocuous and included changes in environmental temperature & stress. Multiple specialities (obstetrics, cardiology, dermatology & anaesthetics) were consulted when formulating a delivery plan. Recommendations varied from elective caesarean section in a specialist centre through to permitting spontaneous delivery in her local unit. After carefully considering the predominantly cutaneous nature of her presentation & patient preference, antenatal care was conducted locally. Her delivery plan included an early epidural & drugs considered unsafe in mastocytosis were clearly documented.
Once spontaneous labour commenced at 40 weeks, the birthing pool was utilised & an intravenous cannula inserted with the aid of topical local anaesthetic. No epidural was requested. Temperature changes in the pool caused a cutaneous reaction, managed by exiting the pool & re-establishing normal body temperature. She had a spontaneous vaginal delivery with the aid of an episiotomy, which was sutured using lignocaine.
Mastocytosis is subdivided into cutaneous and systemic forms, but those with cutaneous varieties may develop systemic symptoms. Knowledge of appropriate drugs & anaesthetic techniques is vital as the risk of anaphylaxis-like reactions is high & women are exposed to multiple triggers during labour. Regional analgesia is safe & low dose epidural mixtures can be used. It is advisable to avoid drugs with high risk of precipitating allergy (suxamethonium) or histamine release (ester local anaesthetics, atracurium, morphine, pethidine). Rocuronium & cis-atracurium are safe choices & fentanyl & remifentanil can be used. The role of prophylactic steroids is not established. It must be appreciated that whilst creating a calming environment has clear benefits, even these simple interventions (e.g. birthing pool) may trigger a reaction.
In conclusion, careful pre-assessment & evaluation of individual disease severity permits the formulation of tailored management plans in mastocytosis parturients. Combined with vigilance & preparation for reactions, this allowed our case to be managed successfully at local level.
1. Mastocytosis & anaesthesia 2014. http://www.rcoa.ac.uk/document-store/mastocytosis-and-anaesthesia
2. Obstet & Gynecol 1995;85:813-5
3. Int J Obstet Anesth 2013;22:243-6