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Severe Cold Contact Urticaria in a Complex Parturient
Abstract Number: SU-30
Abstract Type: Case Report/Case Series
Introduction and Case Summary:
A 29-year-old G3P2 female diagnosed with placenta previa and increta presented to labor and delivery at 24 weeks 5 days gestation for antepartum admission. Medical history was pertinent for cold contact urticaria (CCU), a rare life-threatening condition. The patient described repeated episodes of hives and edema after exposure to cold environments and foods, as well as an episode of severe angioedema requiring intubation after exposure to cold winter weather.
Our obstetric anesthesia team initiated peripartum and perioperative multidisciplinary planning immediately after admission. A cesarean hysterectomy was planned for 36 weeks. Education on CCU and avoidance of cold was provided to all staff caring for the patient in the perioperative period. Intraoperatively, high-dose steroids and antihistamines were given and strict local and systemic normothermia was maintained. No signs of CCU or angioedema were observed. She was extubated in the OR and transferred to the intensive care unit (ICU). Three hours postoperatively, despite continued systemic normothermia and repeat pharmacological treatment, she developed severe lip and airway angioedema requiring emergent reintubation. Prior to onset of these symptoms she received room-temperature IV fluids and a cold mouth swab by the ICU staff who had not previously cared for the patient. She was extubated less than 24 hours later after full resolution of symptoms.
CCU is a rare, difficult to treat form of physical urticaria with significant clinical risks. Evidence of preventative strategies for patients with CCU undergoing surgery is scarce. To our knowledge, this is the first reported case of a high-risk parturient with a known history of severe CCU. Standard prophylaxis includes high dose H1 and H2 receptor antagonists, systemic steroids, and omalizumab (1,2). Although our patient received extensive preventive measures she developed life-threatening complications of CCU in the ICU. The onset of angioedema correlates temporally with the administration of non-warmed IV fluids and cold oral swab. Historically, prior episodes of urticarial resulted from similar triggers. Obstetric anesthesia is uniquely equipped to promote a multidisciplinary approach and further obligated to ensure that comorbid conditions outside the direct focus of the surgical team are adequately communicated to all providers during both the pre and post-operative periods. This includes education of rare conditions that require the utmost vigilance to maximize outcome and minimize harm in parturients with complex pathologies.
1. Paul E, Bodeker RH. Treatment of chronic urticaria with terfenadine and ranitidine. A randomized double-blind study in 45 patients. Eur J Clin Pharmacol 1986;31:277-80.
2. Maurer M, et al. Unmet clinical needs in chronic spontaneous urticaria. A GA(2)LEN task force report. Allergy 2011;66:317-30.