[Intraoperative anaphylaxis to latex in pregnancy].
METHODS
A 31-year-old pregnant woman had to undergo emergency abdominal surgery due to acute intestinal obstruction. The patient's preoperative history demonstrated multiple allergies as well as abdominal trauma several years before. The physical examination--including sonography of the two fetuses--showed no pathological signs. Anaesthesia was induced intravenously with the operating table tilted to the left side, using routine precautions pre-oxygenation, and rapid sequence intubation, and was maintained unproblematically. About 20 min after the onset of surgery, hypotension, tachycardia, and a drop in oxygen saturation appeared. Volume substitution and the application of vasoactive drugs failed to stabilise the haemodynamic situation. Elevation of the pregnant uterus and increased left tilzing of the operating table did not lead to improvement. The development of eyelid edema led to the diagnosis of an anaphylactic reaction. The patient was treated successfully with epinephrine, antihistamines, and corticosteroids (prednisolone). The suspicion of latex-related allergy was verified postoperatively by radio-allergen-sorbent test (RAST) and prick and scratch tests.


CONCLUSIONS
The unspecific symptoms primarily led to the diagnosis of a prostacycline (liberated from the intestines)-induced, so-called eventration syndrome or aorto-caval compression syndrome, respectively, caused by the pregnant uterus [2, 7, 16, 17]. The initial therapeutic failure and the eyelid edema led to the correct diagnosis of an allergic reaction. Besides the application of epinephrine, which was indicated in spite of its vasoconstrictive effect on the smooth muscle of the uterus, immediate left-side-down positioning of the operating table, and sufficient volume replacement were decisive for haemodynamic stabilisation and maintenance of an adequate perfusion pressure of the uterus [7, 8, 13, 15]. Because of the non-specificity of RAST screening, the cutaneous tests had great significance in confirming the diagnosis of latex-related allergy [3, 18, 24].


CONCLUSIONS
Due to the obviously increasing number of latex-related allergies, especially in atopic persons and patients with frequent latex exposure, the patient's exact history is highly significant [4, 7, 18-20]. This includes--because of suspected cross-reactions--questions concerning allergic reactions to bananas and chestnuts [1, 16, 24]. If a latex-related allergy is suspected, all latex- or rubber-containing materials have to be consequently avoided. Because of the suspected allergies by inhalation via rubber-containing masks or tracheal tubes, these devices also have to be avoided and replaced, possibly by silicone materials [1, 4, 5, 16]. Premedication with H1- and H2-antagonists (dimetindene and cimetidine) and glucocorticoids (administered 12h before surgery and given twice) is indicated [5, 19, 12, 21]. In cases of latex allergy, the above-mentioned basic therapeutic measures have to be undertaken even in pregnancy, including immediate replacement of all latex-containing materials. The diagnosis of latex allergy should be verified by cutaneous testing [4, 18, 24].
Obenhaus
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Klinik für Anaesthesiologie und Intensivmedizin, Städtisches Klinikum Wiesbaden.
D000328:Adult; D000707:Anaphylaxis / Q000188:drug therapy / Q000503:physiopathology*; D004837:Epinephrine / Q000627:therapeutic use; D005260:Female; D006633:Histamine Antagonists / Q000627:therapeutic use; D006801:Humans; D007431:Intraoperative Complications; D007840:Latex / Q000009:adverse effects*; D011239:Prednisolone / Q000627:therapeutic use; D011247:Pregnancy; D011248:Pregnancy Complications / Q000601:surgery*; D011852:Radioallergosorbent Test
D006633:Histamine Antagonists; D007840:Latex; D011239:Prednisolone; D004837:Epinephrine