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Considerations for Neuraxial Anesthesia in a Pregnant Patient with Scabies
Abstract Number: RF4BD-118
Abstract Type: Case Report Case Series
Introduction: Scabies is a highly infectious dermatitis involving the mite, Sarcoptes scabei. Its prevalence is worldwide and affects people of all social classes. The female mites burrow into a patient's skin and lay eggs, creating lesions causing an immune reaction. Lesions are mostly found on warmer areas of the body, such as the webbing of fingers and folds of joints. If not treated properly, the lesions can evolve into bacterial infections. The consequences of active infection in patients undergoing surgery is unknown. Even after treatment, there is risk of introducing mite particles into the epidural or intrathecal space during neuraxial placement and this may elicit an allergic response of unknown consequences. Therefore, a systematic approach to neuraxial placement and surgical incision risk in parturients with scabies infections is needed.
Case Presentation: A 21 year-old female G2P1 presented to Labor and Delivery for a repeat cesarean delivery. The patient had a medical history significant for scabies on her abdomen diagnosed two weeks prior while at a routine visit with her obstetrician. She was prescribed permetherin cream and instructed to apply this cream all over her body and rinse off the cream after 8-14 hours.
Anesthesia providers met with the patient on admission and discovered that she had only applied a small amount of cream over her excoriated areas every six hours since diagnosis. On physical exam, the patient was found to have two excoriated areas on her abdomen. The patient had no other excoriations on her body, including her back. The anesthesia providers discussed with the patient about concerns with neuraxial anesthesia with an active scabies infection. Dermatology was consulted and recommended that the cesarean delivery be postponed for a day and that the patient receive adequate treatment. The patient completed the treatment as directed and presented the next day for scheduled cesarean delivery. The anesthesia provider placed an epidural without difficulty and the obstetric team conducted a successful repeat cesarean delivery after chlorhexidine antiseptic was applied. Follow-up with the patient after delivery revealed no concerning signs of an adverse reaction to the neuraxial procedure.
Discussion: Several cases have been published detailing safely administering neuraxial anesthesia in patients diagnosed with scabies, yet guidelines for patients with active scabies infection undergoing neuraxial anesthesia have yet to be established. Most providers emphasized completing a thorough exam of the patient's lower back and sterilizing the patient’s back prior to the procedure, although there is no guidance on the optimal skin antiseptic in these patients. In scheduled cases, thorough discussion and risk assessment for complications with skin incision and neuraxial placement may be warranted.
Kuczkowski KM. Anaesthesia. 2003 Nov;58(11):1140-1.
Thoannes H, Visseaux H, Malinovsky JM. 2007 Jul 1;16(3):293-4.