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Allergy testing during pregnancy – and the culprit is…
Abstract Number: SUN-70
Abstract Type: Case Report/Case Series
We discuss the case of a patient that presents to the labor floor carrying a history of local anesthetic reactions.
32 yo G2P1 at 30 wks gestation consults the OB anesthesia service to discuss options for labor analgesia. As a teenager, she received EMLA topical cream for laser hair removal, and had a delayed reaction that included shortness of breath and throat discomfort. She went to the ED where she was observed without treatment. About one year prior to the current visit she had a primary cesarean section for fetal intolerance to labor. The anesthesiologist discussed the risk and benefits of regional versus general, patient insisted to receive regional anesthesia despite the EMLA reaction, and as her reaction was nonspecific (happened at home, delayed compared to when she received the EMLA, and no drugs were administered in the ED), the cesarean section was performed under spinal anesthesia. 30 minutes after the spinal placement (1.6 mL of 0.75% bupivacaine in 8.25% dextrose, with 100mcg of preservative free hydromorphone and 15 mcg fentanyl), she developed eyelid/periorbital swelling. No shortness of breath/wheezes, no hives, hemodinamically stable. She received diphenhydramine, famotidine, hydrocortisone and the swelling resolved.
Based on her history, she was advised that, without consultation with an allergist, she is not a candidate for local anesthetics. She was not interested either in unmedicated childbirth or general anesthesia for cesarean section, so she agreed to follow up with the allergy clinic. Our service provided the allergy service with a list of medication she received during the case. She underwent skin testing for cefazolin, ondansetron, bupivacaine, lidocaine and chloroprocaine. She had negative skin testing for cefazoin, bupivacaine, lidocaine and chloroprocaine. In addition, the clinic went away and did lidocaine challenge testing, and was completely negative. Our patient did have positive skin testing to ondansetron. Upon reviewing her cesarean section record, ondansetron was the last medication administered minutes before the reaction was documented.
Allergy skin testing (ST) and local anesthetic challenges have been documented in pregnancy (1,2). Negative ST results obtained in pregnancy allow for safe use of the drug at the time of delivery (3). The main concern against doing testing while pregnant is the potential fetal morbidity in case of a maternal anaphylactic reaction. While we do no recommend routine testing in pregnancy, in certain cases, where the results can significantly alter the clinical management, careful testing is in the best interest of the patient. In our case, by testing, potential harm was prevented, as the ondansetron was not on our radar, and most of our patients receive this medication during their stay on labor and delivery.
1. Palmer C, Anesth Analg 1993;77:625-8
2. Balestrieri P Anesth Analg 2003;96:1489-90
3. Macy E, Ann Alergy Asthma Immunol. 2006;97:164-168