|Year : 2020 | Volume
| Issue : 2 | Page : 138-139
Anaesthestic considerations in an obstetric patient with henoch schonlein purpura
Nishigandha Sawant1, Hemlata Iyer2, Vijay Shetty3, Girish Sabnis4
1 Consultant Anesthesiologist, Fortis Hospitals, Mulund, Mumbai, Maharashtra, India
2 Academic Head Anesthesia, Fortis Hospitals, Mulund, Mumbai, Maharashtra, India
3 Head of Anesthesia Department, Fortis Hospitals, Mulund, Mumbai, Maharashtra, India
4 Consultant Obstretrics and Gynaecology, Fortis Hospitals, Mulund, Mumbai, Maharashtra, India
|Date of Submission||31-Oct-2019|
|Date of Acceptance||23-Jun-2020|
|Date of Web Publication||20-Aug-2020|
Dr. Nishigandha Sawant
Fortis Hospitals, Mulund- Goregaon Link Road, Mulund West, Mumbai - 400 080, Maharashtra
Source of Support: None, Conflict of Interest: None
Henoch-Schonlein Purpura (HSP) is an IgA mediated vasculitis predominantly affecting the pediatric population. This disease may leave a lifelong residual effect on renal system with a propensity for a relapse during pregnancy leading to hypertensive and hemorrhagic complications. We present a case of a patient who had HSP in adulthood and had uncomplicated caesarean delivery under regional anesthesia.
Keywords: Henoch-Schonlein purpura and pregnancy, regional anesthesia, renal impairment
|How to cite this article:|
Sawant N, Iyer H, Shetty V, Sabnis G. Anaesthestic considerations in an obstetric patient with henoch schonlein purpura. J Obstet Anaesth Crit Care 2020;10:138-9
|How to cite this URL:|
Sawant N, Iyer H, Shetty V, Sabnis G. Anaesthestic considerations in an obstetric patient with henoch schonlein purpura. J Obstet Anaesth Crit Care [serial online] 2020 [cited 2020 Dec 2];10:138-9. Available from: https://www.joacc.com/text.asp?2020/10/2/138/292746
| Introduction|| |
Henoch-Schonlein purpura is an IgA- mediated hypersensitivity vasculitis common in children and uncommon in adults. It has a severe manifestation when it occurs in pregnancy; even a history of HSP increases the risk of complications during pregnancy. Although prognosis for this condition is reported to be excellent, most studies are based on the pediatric population. The limited literature regarding HSP in pregnancy and its anesthetic implications has provoked interest in publishing this case report.
| Case Report|| |
A 33-year-old primi gravida with 40 weeks of pregnancy presented for labor analgesia. She was a diagnosed case of Henoch-Schonlein purpura three years back. At that time she was hospitalized and treated with oral hydrochloroquine, steroids and discharged with no maintenance medication. During her ante-natal period she was well monitored and did not have any signs or symptoms suggestive of relapse of HSP. Routine investigations like complete blood count, renal and coagulation profile were normal. Her vital signs were normal. For labor analgesia, an epidural catheter was sited in lumbar intervertebral (L3-4) space with due aseptic precautions. Infusion of 0.1% bupivacaine at the rate of 5 ml/hr was given. As there was no progress in labor even after five hours, the patient was posted for lower segment cesarean section. The analgesic effect was patchy and hence a subarachnoid block was given with 10 mg of 0.5% heavy bupivacaine. Adequate spinal anesthesia level was achieved up toT6; a healthy baby was delivered with an Apgar score of 10 at 5 minutes. Patient's heart rate was between 88-110/min and blood pressure was 100-120 mmHg systolic during the cesarean section. Blood loss was approximately 350-400 ml. Intraoperatively, one litre of ringer lactate was given as intravenous fluids and the urine output was 300 ml. Postoperatively, pain was managed with epidural infusion of 0.1% bupivacaine at 5 ml/hr. Patient was discharged home on fifth day.
| Discussion|| |
Henoch-Schonlein purpura is a leucocytoclastic vasculitis. It is a disease of the skin, mucous membrane and sometimes other organs. It mostly affects children, peak incidence being between 2 and 6 years of age., The cause of HSP is multifactorial such as bacterial or viral infection, drug-induced or genetic.,
Occurrence of HSP during pregnancy is very rare. Patients may present in pregnancy with past history of HSP, with or without renal function impairment, relapse of HSP during pregnancy or new onset HSP with active purpura. Twenty cases of HSP during pregnancy have been reported in the literature so far. Reports support that patients with prior history of HSP and no residual renal damage usually have a favorable outcome but in those with renal damage, complications like spontaneous abortions, preterm delivery, intra- uterine growth retardation and maternal hypertension due to nephritis are seen. End stage renal disease may develop as long as 20 years from diagnosis of HSP. Pregnancy itself may be a trigger event for recurrence in individuals who had a past history of HSP.
Maternal hypertension maybe due to hormonal changes that affect the cell mediated immunity and the renal impairment due to hyper filtration during pregnancy., As IgA immunoglobulin does not cross the placenta, fetal morbidity seems to be due to maternal renal and hypertensive complications rather than to HSP itself.
Our patient had a history of HSP 3 years ago with no residual renal damage. Possibility for relapse was kept in mind which was ruled out by her normal complete blood count and renal profile. Chronic infective foci or chronic tonsillitis can also precipitate HSP relapse. Any such recent history of infection was ruled out during the antenatal period in our patient.
The effect of pregnancy during active HSP has varied outcomes. Analysis of four cases reported in literature shows aggravation of disease in two patients, diminution of proteinuria in one patient and disparities of symptom in one patient. Apart from the classic triad (purpura, arthritis, abdominal pain) more severe manifestations such as necrotizing cutaneous ulcerations or acute renal failure may also be seen. Treatment is corticosteroids as it is beneficial for arthritis, gastrointestinal symptoms and has a protective effect against nephritis. Plasmapheresis may be used in case of progressive renal failure. Other immunosuppressant like azathioprine, cyclophosphomide are also used but there is no consensus regarding the exact treatment. These patients should be counseled before conception and screened for renal profile As they are at increased risk of complication during pregnancy they should be monitored closely with a multidisciplinary approach involving an obstetrician, nephrologists and anesthesiologist. Routine hematological work up includes hemogram, coagulation profile and renal profile.
Plan of anesthesia can be decided upon the patient's clinical condition. There is no consensus about the best anesthetic technique. These patients are known to have abnormal platelet aggregation, increased D-dimer levels and reduced Factor Xlll level which leads to bleeding risk during pregnancy. If standard coagulation tests including platelet count are normal, then regional anesthesia is not contraindicated. Acute phase is associated with hypercoagulability as seen with increased D-dimers, neuraxial blockade is then contraindicated. Our patient was not in active phase and had no cutaneous lesions or purpura. Hence, regional anesthesia was planned for the delivery.
While planning general anesthesia for these patients who are in active phase, care should be taken to reduce the risk of tissue damage and necrosis while patient positioning, blood pressure monitoring and endotracheal intubation and avoiding nephrotoxic drugs. It is important to note that HSP like nephritic syndrome (proteinuria), abdominal pain, headache and convulsions may resemble symptoms of preeclampsia or eclampsia. Our patient did not have any of these signs and symptoms, her blood pressure was normal and had no proterinuria throughout the pregnancy.
| Conclusion|| |
Regional anesthesia was successfully employed for labor analgesia and lower segment cesarean section in a patient with previous history of HSP with no residual renal damage. Regional anesthesia can be administered in such patients as it avoids the use of Non-steroidal inflammatory drugs for postoperative analgesia.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Saulsbury FT. Clinical update: Henoch-Schönlein purpura. Lancet 2007;369:976-8.
Chakrabarti SB, Tigga MP, Ray J, Debbarma A. Henoch schonlein purpura in pregnancy: A lesser known phenomenon. Int J Reprod Contracept Obstet Gynecol 2015;4:1227-30.
Hoshino C. Adult onset Schönlein-Henoch purpura associated with Helicobacter pylori infection. Int Med 2009;10:847-51.
McCarthy HJ, Tizard EJ. Clinical practice: Diagnosis and management of Henoch-Schönlein purpura. Eur J Pediatr 2010;169:643-50.
McCarey C, Boehlen F, Savoldelli GL, Moll S, Irion O, Martinez de Tejada B. Henoch-Schönlein purpura in pregnancy: A case with uncomplicated maternal and neonatal outcome. Int J Gynecol Obstet Neona Care 2015;2:30-4.
Jauhola O. QULU 2012. D 1151. Henoch-Schonlein purpura in children May 2012. p. 40.
Cummins DL, Mimouni D, Rencic A, Kouba DJ, Nousari C. Henoch-Schönlein purpura in pregnancy. Br J Dermatol 2003;149:1282-5.
Kalamantis K, Daskalakis G, Lavazzo C, Vranos A, Mesogitis S, Antsaklis A. Henoch-Schonlein purpura in pregnancy. J Obstet Gynaecol 2008;28:403-5.
Labib R, Sharih G, Geoghegan J. Epidural anaesthesia for a parturient with Henoch-Schonlein purpura. Int J Obstet Anesth 2011;20:372-3.
Erol DD. Perioperative management of a patient with Henoch-Schonlein purpura for appendicectomy. Saudi Med J 2006;27:714-6.