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 Table of Contents  
Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 95-96

Impetigo herpetiformis and pregnancy: Anesthetic management for caesarean delivery

Department of Anesthesiology, Burdwan Medical College, Burdwan, West Bengal, India

Date of Web Publication7-Nov-2017

Correspondence Address:
Susmita Bhattacharyya
Department of Anesthesiology, Burdwan Medical College, Burdwan, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joacc.JOACC_11_16

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The case report presented here is of a primigravida who was admitted with impetigo herpetiformis and was planned for an emergency caesarean section due to fetal distress. General anesthesia was administered. Immediately after extubation, she developed severe laryngospasm, which was relieved by administration of intravenous calcium gluconate. Rest of the postoperative period was uneventful.

Keywords: Caesarean section, calcium gluconate, general anesthesia, impetigo herpetiformis, laryngospasm

How to cite this article:
Bhattacharyya S, Das D, Mandal KB. Impetigo herpetiformis and pregnancy: Anesthetic management for caesarean delivery. J Obstet Anaesth Crit Care 2017;7:95-6

How to cite this URL:
Bhattacharyya S, Das D, Mandal KB. Impetigo herpetiformis and pregnancy: Anesthetic management for caesarean delivery. J Obstet Anaesth Crit Care [serial online] 2017 [cited 2022 Aug 13];7:95-6. Available from: https://www.joacc.com/text.asp?2017/7/2/95/217767

  Introduction Top

Impetigo herpetiformis (IH) is a rare dermatoses that generally appears as pustular eruption during third trimester of pregnancy and it tends to remit after delivery.[1] It is characterized by acute erythematosquamous plaque covered with tiny superficial pustules in a herpetiform distribution.[2] IH can cause serious maternal hypocalcemia, placental insufficiency, still birth, or other fetal abnormalities. We are presenting a case of impetigo herpetiformis scheduled for an emergency caesarean section. Written consent to publish details of the case was obtained prior to the procedure.

  Case Report Top

A 22-yr-old, 50 kg, primigravida was presented at 37 weeks of gestation in the emergency department with history of generalized painful pustular eruption over her back, arms, and legs, which was started at the later months of her pregnancy. She was posted for emergency caesarean delivery (CD) for fetal distress. Her pulse rate was 100/min, blood pressure was 130/80mm of Hg. Bilateral vesicular breath sounds were heard over all lung fields. First and second heart sounds were audible. No murmur was detected. There was no edema or exfoliation of the buccal mucosa. Her Mallampati grade was II. As her back was involved with pustules, general anesthesia was planned with rapid sequence induction (RSI). At the operating room (OR) an intravenous (i.v) line was established with 18-gauge cannula and secured to the skin with non-adhesive dressings. Multi-channel monitor was attached with extreme care to avoid adhesive application over involved skin areas to prevent exfoliation.

The patient was instructed to take four vital capacity breath for preoxygenation. Induction of anesthesia was done with 100 mg propofol i.v. Intubation was performed after administration of succinylcholine (50 mg) under direct laryngoscopic vision with 6.5 mm ID cuffed endotracheal tube applying Sellick's maneuver. The tube was fixed carefully with bandage avoiding excessive pressure over the skin. Maintenance of anesthesia was achieved with oxygen and nitrous oxide in 50:50 ratio, which was changed to 30:70 after delivery of the baby along with isoflurane (0.5% dial concentration). Muscle paralysis was maintained with vecuronium bromide (4 mg). Fentanyl 100 mcg and oxytocin (20 units) infusion were given i.v after the birth of the baby. The Apgar score was 4 and 10 at 1 and 5 minutes, respectively. Patient was extubated at the OR after administration of neostigmine (2.5 mg) and glycopyrrolate (0.5 mg). Immediately after extubation, patient developed severe laryngospasm and rapid desaturation occurred. The jaw-thrust and head tilt maneuver combined with positive pressure ventilation with oxygen via a tight fitting face mask were applied for ensuring a patent airway. Gentle oropharyngeal suction was done to remove secretions and blood. But laryngospasm was not relieved. Carpopedal spasm (flexion of the wrist and metacarpophalangeal joints, extension of the interphalangeal joints and adduction of the fingers) was observed. Assuming hypocalcaemia, 10% of 10 ml calcium gluconate was given over 10 mins and the same dose was repeated. Laryngospasm was relieved. Blood was sent for serum calcium estimation and the value was 6.4 gm%. Calcium gluconate infusion was started at the rate of 0.5 mg/kg/hr for next 24 hours. Patient was shifted to the recovery room.

  Discussion Top

Spinal anesthesia (SA) is the commonly used technique for CD. Local site infection is one of the contraindications of administration of SA. In IH, initially pustules are sterile. But they may become secondarily infected in the subsequent period and if untreated can lead to fever and bacteremia. SA can be given in patients with IH after targeted topical steroid therapy in the lumber region. There are reports of administration of SA in IH.[3],[4],[5] This patient presented in the emergency with fetal distress without any prior treatment for IH. So general anesthesia with controlled ventilation was administered following the usual steps. After extubation, sever laryngospasm developed which was not resolved by the conventional therapy but subsided after i.v. calcium administration.

Role of calcium has been described in this disease process and treatment of hypocalcaemia may regress this disorder.[6] Respiratory alkalosis secondary to hyperventilation is the most common cause of acute fall of serum ionised calcium (Ca ++). When serum pH increases the binding between calcium and protein is enhanced, resulting in decreased serum Ca ++. Hyperventilation due to labour pain and positive pressure ventilation during general anaesthesia might be responsible for respiratory alkalosis in this case. There are reports of hyperventilation syndrome induced by anxiety and stress before induction and after awakening from general anaesthesia in patient without central nervous system and psychiatric disease under general anesthesia.[7] Hypocalcemia leads to increased neuromuscular irritability and may present with circumoral numbness, paraesthesia of the hands and feet, carpopedal spasm, laryngospasm, focal or generalized tonic muscle cramps, or seizures. Myocardial dysfunction and prolongation of the QT interval may also occur. There was no arrhythmia in this case. Carpopedal spasm may be positive before other manifestations of hypocalcemia.[8] If carpopedal spasm appears, treatment with intravenous Ca ++ is indicated until the signs and symptoms of hypocalcaemia subside without waiting for serum calcium levels.[9] Laryngospasm was relieved after administration of calcium gluconate in this case.

In conclusion, CD was successfully performed under general anesthesia in a case of IH and postoperative severe laryngospasm was corrected by exogenous calcium supplementation.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Ingber A. Impetigo herpetiformis. In: Ingber A, ed. Obstetric Dermatology: A Practical Guide. Berlin: Springer; 2009. pp. 135-42.  Back to cited text no. 1
Roth MM. Pregnancy dermatoses: Diagnosis, management, and controversies. Am J Clin Dermatol 2011;12:25-41.  Back to cited text no. 2
Pemberton O, Callender L. A Cesarean section under spinal anaesthesia for a patient with pustular psoriasis. Anaesthesia 2009;64:793-813.  Back to cited text no. 3
Samieh-Tucker A, Rupasinghe M. Anaesthesia for caesarean section in a patient with acute generalised pustular psoriasis. Int J Obstet Anesth 2007;16:375-8.  Back to cited text no. 4
Kondo RN, Araújo FM, Pereira AM, Lopes VC, Martins LM. Pustular psoriasis of pregnancy (Impetigo Herpetiformis) - A case report. An Bras Dermatol 2013;88:186-9.  Back to cited text no. 5
Fouda UM, Fouda RM, Ammar HM, Salem M, Darouti ME. Impetigo herpetiformis during the puerperium triggered by secondary hypoparathyroidism: A case report. Cases J 2009;2:9338.  Back to cited text no. 6
Mizuno J, Morita S, Itou Y, Honda M, Momoeda K. Hanaoka Hyperventilation syndrome before induction of and after awakening from general anaesthesia. Masui 2009;58:768-71.  Back to cited text no. 7
Kumar V, Abbas A, Fausto N. Pathologic Basis of Disease. 7th edition. Philadelphia: Elsevier-Saunders; 2005. pp. 1188.  Back to cited text no. 8
Bringhurst FR, Demay MB, Kronenberg HM. Hormones and disorders of mineral metabolism. Wilson JD, Foster DW, Kronenberg HM, Larsen PR, editors. Williams textbook of endocrinology. 9th ed. Philadelphia: WB Saunders; 1998. pp. 1155-209.  Back to cited text no. 9


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