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Anesthetic Management of a Patient with Pruritic Papules in Third Trimester: Neuraxial vs. General Anesthesia?
Abstract Number: T-22
Abstract Type: Case Report/Case Series
Parturients with a rash present a unique challenge to the anesthesiologist with regard to the safety of neuraxial analgesia/anesthesia. There is a risk of introducing infection from the skin into the central nervous system (CNS) with needle placement, which can result in meningitis and encephalitis.
33 year old G4P2012 presents to the emergency department at 37 weeks gestation for evaluation of diffuse pruritic papules. She was in her normal state of health up until three days prior when she noticed a rash that almost entirely covered her extremities, abdomen, chest, and back. On skin exam, there were numerous 1-2mm pink papules/pseudovesicles. Dermatology consult performed a punch biopsy. The patient was afebrile and had a normal white blood cell count. The obstetricians decided to induce labor for a 4/8 biophysical profile. A non-reassuring fetal heart rate developed so a cesarean delivery was planned. Despite no signs of acute infection, we decided to perform general anesthesia since dermatology was unable to diagnose the rash (the biopsy results were pending and the patient did not have an area of her back unaffected by the rash). The anesthetic and delivery were uneventful. The biopsy results showed likely spongiotic eczematous process consistent with prurigo gestationis.
One contraindication to neuraxial techniques is thought to be infection at the site of needle insertion. Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy (PEP), is the most common cause of rash in pregnancy.(1) While it is safe to perform neuraxial techniques in patients with PEP if affected skin in avoid (due to risk of bacteria at the site of excoriations), there is a risk of epidural abscess.(2) While it seemed prudent at the time to avoid neuraxial anesthesia in this patient, prurigo gestationis is a benign atopic dermatitis. When neuraxial techniques are employed in patients with rashes, it seems best to avoid needle placement at the site of skin lesions due to the risk of introducing bacteria or virus into the central nervous system.
1.J Reprod Med 2005; 50: 61-3.
2.Can J Anesth 2006; 54: 1010-14.