406. Caesarean section in a labouring parturient with stress induced anaphylaxis

Abstract

A 32-year-old primigravida presented to the Maternal Assessment Unit in spontaneous labour contracting regularly with a 36 h history of prolonged rupture of membranes. The patient had a 7 year medical history of Stress Induced Anaphylaxis (SIA). This was triggered by particular foods followed by exercise. The patient had been taking regular antihistamines prior to pregnancy and carries an epi-pen. Unfortunately the patient presented to the Maternal Assessment Unit in established labour in the early hours of the morning. The patient had no anaphylactic symptoms on presentation. 150 mg IV hydrocortisone and IV antihistamine were given prophylactically. A decision was made to proceed to caesarean section. We collectively felt that a spinal anaesthetic was the most effective way of blunting any evolving stress response to labour. An uncomplicated caesarean section was performed under spinal anaesthetic and the patient was discharged home well on Day 3 postoperatively. Stress or Exercise Induced Anaphylaxis was first described in 1980 by Sheffer and Austen1. To date there are only five cases of SIA in pregnancy in the literature2–6. Given the fact that this patient presented in labour and was at higher risk of potentially developing stress induced anaphylaxis we felt that a spinal anaesthetic would be the most efficient and safest method of blunting the stress response and thus preventing anaphylaxis. Although it is reported that morphine and other histamine releasing drugs should be avoided in this patient cohort[f], it is important to note the our patient received intra-thecal morphine prior to caesarean section without complication. This case also highlights the importance of thorough multidisciplinary antenatal care in order to plan for such complex patients should they present out of hours in labour. From the evidence to date, if these women do proceed to labour IV hydrocortisone, IV antihistamine and early epidural is recommended.